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Area SPECIAL Well Permit WAIVER Received Employee IDit ft Constructed Well Depth //6.2--o231-3 WELL /PUMP PERMIT EHO 43-06 S/01/16 WELL/PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - SrocicroN CA 95205 - (209)468-3420 NON-REFUNDABLE PERMIT CALL 09) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS 222 -1 f,-- Rilitg, 12-di cm,. -ESGaiON, Ddi t1-,0 CROSS STREET Et XIONI Elk APN 2.19-20-- NO PARCEL SIZE ill LAND USE APPLICATION # OWNER NAME Ue NI 1\1 VaKlizu1,6 PHONE 20q.us2. U8/72— OWNER ADDRESS 2-22 61 E rz-Itites FA/ CiTYISTATE/ZIP rs-GaioN 64 4937'0 CONTRACTOR PAscois Dt IIIII.J140. PHONE jog- 522-- . 1 012g- CONTRACTOR ADDRESS oil /flit Ps' CITY/STATE/ZIP A/loan Ca ci57 SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS CITY/STATE/ZIP LICENSE )(C-57 0 C-61 0 D-09 L Other NUMBER OU KV-2-- EXPIRATION DATE 01 .-3O .2-02-1 DOMESTIC WELL SAMPLING: 91 General Mineral/Coliform Bacteria (4391) CAtibromochloropropane (4392) 7.i Arsenic (4393) INTENDED USE Wornestic/Private 0 Irrigation/Agricultural C Industrial El Water Quality Monitoring 0 Soil Sampling/Characterization C Public Water System If different from Owner Water System Name Contact Name or Phone Number TYPE OF WORK :J New Well )(Replacement Well iii Well Alteration/Modification E Other Li Monitoring Well(s) # of wells 3 Soil Boring(s) *of borings L: Geotechnical s of borings - Out-Of-Service Well D Out-Of-Service Well Renewal F_," Cross-Connection Repair i._ New Pump 0 Pump Replacement 0 Pump Repair ri Raise Well Casing WELL CONSTRUCTION Drilling Method XMud Rota 0 Air Rotary 0, Auger iii Cable Tool u Push Point C Other i Proposed Well Depth ft Excavation I I " in diameter 0 Open Bottom 0 Gravel Pack/Gravel Sizeir 10 in diameter E Conductor Casing in diameter / Conductor Rasing Depth ft Casing Diameter in Thickness/Gauge/ASTM Sched .2.4JV ,i: Steel X Plastic 0 Stainless Steel 0 Other Well Grout Seal Depth j OO fl u Neat Cement (94 lb bag/5-10 gal water) E Sand Cement sack mix/7 gal water )(Bentonite (20% solids) 0 Other Grout Placement Method 'Pumped 0 Free Fall 0 Other 3 Retardant / Accelerator (name) PEDESTAL Installed By E Driller 0 Pump Contractor E Other 0 Concrete Pedestal DDimensions: Width ft Length ft Thick in 0 Christy Box : Stove Pipe PUMP I] Submersible: Turbine 0 Other HP Pump Set ft Standing Water Level ft I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE WORKERS COMPENSATION LAWS. MINI A"... b.:41Q ri ,. I • NCE NOTICE REQUIRED FOR V ; iti Fa EC TITLE THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN I ALSO CERTIFY THAT MY REQUIRED LICENSE IS LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL IN PECT ONS - PLEASE CALL (209) 953-7697 il I I I I 4 I DATE ko.7.1/19 SIGNED w - 4 I in EN . Ell PI ,MISIWIEEI, 136511111 *AM ME 211111PAIIIMAINIffe1 EINNIMIIIIMiimmi= 1 / 12.12.1 ma r.• u u_•uuiuuu.uU ,. • • • .II. NE MIIIIT Z ifflIIPII. -.. _ ,, NI minahmai I'. " P 111111111111611EWM SOIONALTAMMENIMIIIMMmuiuuuuuu uuLU&!aI!PA WAIMIKVATOMIREINIMS. , MINIIIIIIPORIM I 111W11111111PRIMPLIIIKOM1111/111 INIERIIIIIPM" 1 ' l'. . ISEPPAMIAIIME IMMIIIII MOStird'AMMIIIIWITi 11111UPLI LEMAN' r. DEPARTMENT USE ONLY Application Accepted By Z-- Date Grout Inspection By Date Pump Inspection By Date Soil Boring Inspection By Date COMMENTS PE Codes SC Into Received B.., Check* Amount Remitted Date , Permit/ Serylp Request I Invoice # Well IDS 13 i,-, ,' . Ger 1 vFash 1 i2,0.74pc)Wift, /..i 9.5c: i 4 if, 4 iy5- /Stec: 1 , , .-13c;d //(..,,,--- I, :SS311Clay 311S