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WELL/PUMP PERF Ifn <br /> /f P SAN JOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON kJENUE•STOCfiON CA 95205-(209)468-3420 <br /> NON REFUND E PE CALL 209.95?-7 97 Fop I eons EXPIRES 1 YI:AIt F DATE lssuEp <br /> U0 / „L' <br /> JOB ADDRESS 1 CITY(ZIP m <br /> CROSS STRE£2NPORW I APNL �/ �V PARCEISVE4a( USE APPUCATION# I o <br /> OWNER NAME Y1 h)�) V./ PH <br /> OWNER ADDRESS `� ITY A W <br /> ;ONTRACT t/1. // J LJ NONE <br /> 1?6cf J49IX <br /> Q i <br /> CONTRACTORADAR/ESS / IP "J D <br /> SUSCONTRACTOi�• NE <br /> lY <br /> SUBCONTRACTOR ADDRESS / _ _ CITY/STATEMP IV M <br /> ` I <br /> V , L,CENSE -C-57 C-61 D-09 Other I NUMBE �Ur E)�IRATION DATE L <br /> 11 1 <br /> DOMESTIC WELL PILING: General MineraUCollform Bacteria,4391 1 Dibromochioropropane(4392) Arsenic(4393) I <br /> E, <br /> INTENDED USE V DomesbdPnvate ImgatioNAgneultural Industrial `Nater Quality Monitoring Sal SamplinglCharactenzation <br /> Pubic Water System !j <br /> i}t;dlerenl fror•Jwrer. Nater System Nam* Contact Nana or Phbne Number <br /> TYPE OF WORK New Well Replacement Well Well A!Ieratio�, ocifcabon Other i <br /> Monaoring'Nell(si x of wells Sod BCrrg:S 'of oonnss Geotechnical e r bcnngs <br /> Our-Of-Service Well Out-01,-Seimce'r'.ell Renewal Cross-Connection Repair <br /> NL,,?urr;rN Pump Replacement Pump Rel:-;r Raise Well Casing j <br /> WELL CONS'LRUCTIQN I ! ^ <br /> a` <br /> Drilling Method Mud otary Air Rotary Auger Caole-a-. Gush Point <br /> Proposed Well Depth ft Excavation r,dia�-a; Otner <br /> 6r Open Bottom Gravel Pack/Gravel Size in diameter) I� <br /> Conductor Casing in diameter i Conc::ctor Casing Depth <br /> „ `IL Well Casino Diameter_:n Thickness/Gauge/ASTM Sched Steel Plastic Stainless Steel Other <br /> Grout Seal Depth ft Neat Cement(94 Ib bagr5--,4 ga;water/ Sand Cement sack mix!7 gal water <br /> Bentonite(204 solids) Other <br /> Grout Placement Method Pumped Free Fall Other Retardant/Accelerator(name) f J0, '?01 <br /> PEDESTAL Installed By Driller Pump Contractor Other An. Q(j <br /> Concrete Pedestal Dimensions:Width_R Len th ft Thick in .Christy Bos Stov Pipe C•V/RoN N cou <br /> Ty()4 FNTg4 T), <br /> PUMP Submersible Turbine Other nP Pump S t -It Standing Water Level RT,yENT <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT i AM IN COMPLIANCE)NTH ALL <br /> WOPARSXQMPENSATION LAWS. <br /> UM 24 H DV CE NOTICE REQUIREr 345PECTyIIO/N�%S/ PLEASE CALL(209) 7(711 G <br /> SIGN TA - 'U_/ / [ll�! S DATE J t <br /> l jLNIV <br /> I l i <br /> i ! <br /> 1 i <br /> r1 1 T \ Ir I <br /> � r 1164 L <br /> ak <br /> _ i I <br /> j I j 2019 <br /> l l ,� <br /> IlkITT NIA1:01CALT11 <br /> e RTMEN NT <br /> US N V <br /> AeoiiL<;:on„cceotec 3y Oa[e 7 � AreaEmployee!Dz � <br /> uroct inspection By Date SPECIAL ell Permit <br /> �,xr;!nspecbon By� [��t� [���;' 4LAJ Date WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth <br /> It <br /> ]:•rtt_N�5 <br /> PE SC Received i C Amount Permit) <br /> ucades Info ash iced Oat Service Request 9 Invoice: Well 10# <br /> 01 (0 -� <br /> i <br /> zg2- <br /> --. ..•e WELT.'K,MP PERMIT <br />