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WELLIPUMP PERMIT <br /> SAN JONQUIN COUNTY EfmRoNMENTAL HEALTH OEPX�TMIENT 1868 FAST HAZELTON AvENUE-STOCK CA 95205-6232 (209)468-3420 <br /> A 7E ISSUED <br /> NON-REFUNDAP t'WVf W.s V.orgle hd EXPIRES I Y FROM DAI <br /> PERM <br /> CITY'IF <br /> Jos ADDRESS /ZI C-1 j M <br /> I <br /> 'CROSS STREET e PARCEL.SIZEC?l LAND USE APPLICATION# <br /> 0 L4 <br /> OVVNER NAME 0 tt - — <br /> 1�111nd(4 PHO <br /> Z <br /> OWNER ADDRESS A4 tj 0 It(A r <br /> 7,A <br /> GONTRACT01 ZT t(4 <br /> PHONE <br /> CITYISTnATE OE*P <br /> CONTRACTOR ADDRESS <br /> SUBCONTRACTOR/CONSULTANT PONE <br /> tv Crry/S <br /> SUBCONTRACTOR/CONSULTANT ADDRESS )TATEIZIP <br /> (ob EXPIRA70N, <br /> LICENSE C-57 NUMBER IDA? <br /> i x C-61 D-09 Other <br /> 1 BILUNG PARTY: OWNER CONTRACTOR 7 SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING: =General Vi".rieralj'Colifji-rn Bacteria(4391) = Dibromocliloropropane(4392)_ Arsenic(4393) <br /> LNTENDED LJSE ADomestic/Private ­ Irrigatior./Agricuitural -- Industrial Water Quality Monitoring - Soil Sampling/Characterization <br /> - Public Water System___­. <br /> If different from Owner. WaterSystemName Contact Name or Phone Number <br /> I - <br /> TYPE OrWORK - New Well Replacement)PIe'! Weil Alteration/Modification Other <br /> - Monitoring Well(s)_---'of wells 7 Soil Eorino(s) #of borings Geotechnical 'I of borings <br /> - Out-Of-Service WellOu�Ot-Service Wpll Renewal Cross-Connection Repair <br /> - New Pump Pur�,uLP-eol�Le, - Pumo Repair Raise Well Casing I� <br /> WELL.i C 2_KSr_ Tj <br /> RUg ON ZZ jj _ I — <br /> Drilling Method - Mud Rotary Aj., RotRP/ Augef - Cab:eTool Push Point Other 1 11' ft Excavation .:n diameter Open Bottom '- Gravel Pack/Gravel Size in diameter <br /> i I-raposed Well Depth__ meter <br /> Conductor Casing ind';Frnater j Conductor Casing Depth_ ft <br /> Weil Casing Diameter in Sched _ Steel -, Plastic - Stainless Steel � Other <br /> Grout Seal Depth ft Neat Cement(04/b bag/5-90 gal water) 7, Sand Cement sack mix17 gal water 11ro <br /> Bentonite(20%solids) = Other—----- <br /> Grout Placement Method - Pumped .7 Free Fail 7 Otr!er 7 Retardant/Accelerator(name) <br /> PEDESTAL Installed By 1- Driller Pump ContraC'.or Other I <br /> Concrete Pedestal LDirnanslons:Width—ft Length ft Thick in Christy Box � Stove Pipe <br /> Lump Submersible— Turbine Other HP Pump Set ft Standing Water Level ft <br /> I HEREBY CERTiFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUN11Y 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 WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> I IMPPIUM 8 HOURKADIVAIAWE NOTiCE REQUIRED FOR INSPECTIONS - PLEASE CALIL �209) 953-7697 <br /> "' "' U <br /> SIGNEDII-S& TLE_ DATE- <br /> CA <br /> Ah W <br /> wo <br /> MEW <br /> ... ..... ..... _j I j. <br /> nrj�Ll M N I <br /> DEPARTMENT USE ONLY <br /> Application Accepted By le=— Date)-a mhw;Za <br /> Grout Inspection By Date Area M-,-tq Employee ID# PIZ, <br /> Pump Inspection By El SPECIAL Well Permit <br /> kon"�', 7 Date IWMAJ972— -1 WAIVER Received <br /> Soil Boring Inspection By — Date Constructed Well Depth <br /> COMMENTS ft <br /> PE SC Received Check#1 --Amount Permit/ <br /> Codes Info Cash Remitted Date Service Re juest# Invoice# Well ID# <br /> 477 <br /> EHD 43-06 6/11/2019 <br /> WELL/PUMP PERMIT <br />