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WELLIPUMA.F" PERMAH"T <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232 (209)468-3420 <br /> NON-REFUNDA. LE ERMIT W'AP1V*V.S' ov.Org/phd EXPIRES 1 YEAR.From DATE ISSUED <br /> A Vj tC CA <br /> rp 0 Y/Z <br /> Jue Ar-,oREss q IT IP <br /> > <br /> CROSS STREET 3 4 <br /> RF F --.__—PARCELSIZE 17.67:!�LAND USE APPLICATION# <br /> mi <br /> OWNER NAME ell r PHONE <br /> OWNER ADDRESS CITY1STA1'ErZIf&r1� 11�(X <br /> ,�, J rsQn U!,"'(.',NTRACT0R PHONE a �a� _ <br /> L4 H L4 <br /> t)6 CiTY/ <br /> q STATE17-P CCA <br /> CONTRACTOR ADDRESS <br /> SUIiCONTPACTORICONSULTANT WPHO� E <br /> `SUBCONTRACTOR/CONSULTANT ADDRESS CITYISTA IZIF <br /> LICENSE C-57 'y C-61 0-09 Other13-2 NUmsE Q-7&16(pb EXPIRATION DATJ <br /> BILLING PARTY: OWNER Y CONTRACTOR 7 SUBCONTRACTORICONSULTANT <br /> DOMES11"WELL SAMPLING: -7 General Mineral/Coliform Bacteria(4391) = Dibromochloropropane(4392)--.Arsenic(4393) <br /> 7 <br /> �.. <br /> N4.-_- <br /> ENDED 1JV*,E - Domestic/Private <br /> figation/Agricultural _ industrial Water Quality Monitoring _ Soil Sampling/Characterization <br /> - Public Water Syst <br /> If different from Owner. Water System Name Contact Name or Phone Number <br /> New Well L Replacement Well - Well Alteration/Modification Other <br /> yp <br /> Monitoring Well(s)_ _4 of wells 7 Soil Boring(s) ti af borings Geotechnical of borings <br /> 01.it-Of-Service Well - Out-Of-Service Well Renewal - Cross-Connection Repair PA <br /> LYM <br /> New Pump Pump Replacement 7 Pump Repair - Raise Well Casing PAIII <br /> I <br /> WELL CONSTRUCTION Vtb <br /> DrOing Method - Mud Rotary Air Rotary - Auger - Cable Too[ Push Point Other f)A <br /> :iliopwaed,Well Depth ft Excavation in diameter Open Bottom - Gravel Pack/Gravel Sizejo iameter <br /> U <br /> i Conductor Casing indiarneter ' Conductor Casing Dept, ft -5AtVj_i�� <br /> e1VVAQIj1Aj C <br /> 1) <br /> Stainless <br /> IlVialf Casing Diameter in Thickness/Gauge/ASTM Sched Steel _' Plastic M_4p'2UAlrV <br /> I ft <br /> Grout Seal Depth ____ft Neat Cement(941b bag/5-10 gal water) 7 Sand Cement- Int I ) <br /> jWI water <br /> Bentonite(20%solids) Other <br /> G;ri)vt Placement Method Pumped Free Fall F Other Retardant I Accelerator(name) <br /> Installed By -- Driller Pump Contractor Other <br /> Concrete Pedestal�Dimensions:Width.__ft Length ft Thick in Christy Box Stove Pipe <br /> PUMP Submersible Turbine 7 Other-----. HPPump 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 COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS, I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CAL;Ff'.)RNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> VIJORKERS COMPENSATION LAWS. <br /> F1.11 III IN3 E HOUR ADVANICE NOOK," RECQUIR""Z) VN1S3P1r-zC_T10NS -PLEASE CALL (209J 95 -767 <br /> SIC-NED TiTLE DA, Z/() <br /> A <br /> 7- <br /> +1 <br /> N <br /> -+J <br /> 7 <br /> -4-r <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date 1OLjq1;o e� Area SICN4 Employee ID# <br /> I <br /> Grout Inspection By Date Ej SPECIAL Well Permit <br /> Pump Inspection By it"1 Date L1 I q f-WIA2— F1 WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received (Vieck#D) Amount Date Permit/ Invoice# Well ID# <br /> Codes Info <br /> Remitted Service Re st# <br /> F <br /> 14391 aSO +72 <br /> EHD 43-06 6/1'/2019 WELL/PUMP PERMIT <br />