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EI-ID 43-06 6,11,2019 WELL /PUMP PERMIT <br />doeART ENT US 0 LY <br />.:VIA . <br />iliglirgint _411 Date 0 0 <br />* Date <br />Date <br />m <br />beticEmployee ID# <br />SPECIAL Well Permit <br />WAIVER Received <br />Constructed Well Depth CA. ft <br />1A ( <br />Application Accepted By <br />Grout Inspection By <br />Pump Inspection By <br />PE <br />Codes <br />SC <br />o <br />Received Check#1 <br />Cash.----- <br />Amount <br />Remitted Date Permit/ <br />Service Ro9uest 8 Invoice I Well IDIf tw ( point <br />4j " <br />t t 2_ <br />412 0 <br />(WM vvvANIN) <br />Area <br />Soil Boring Ins <br />COMMENTS <br />4)14-4 7. <br />tion By <br />f4LAT Fiom <br /> PAYMENT <br />RECEIVED <br />P 0 4 2019 <br /> JOAQUIN COUNTY <br />eNVIRONMENTAL <br />H DEPARTMENT <br />*)C <br />WELLJPUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 .6232 (209) 468-3420 <br />NON-REFUNDABLE PERMIT www.lv.orgiehd EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS <br />CcrS E —k- c,,,zp ii carvA7 0 '/ S 2:2—C) <br />CROSS STREET...Fri/1 f...- I 1 4 tris APN a) /f.)0 - PARCEL SIZE LAND USE APPLICATION # <br />c <br />OWNER ADDRESS CO '.)(3)C Lb 0 CITY/STATE2IP 4 C C\ 711€ 0 Ce\ 752-2d <br />CONTRACTOR .1)(A.1 .(\a!'S LL .e 'Y‘-3 PHONE 53a- 733 -5 <br />CONTRACTOR ADDRESS CO TIC, )c 're CI 11O. Cm/STATE/ZIP 0 0 0 01. i")C'4 <br />SUBCONTRACTOR/CONSULTANT PHONE <br />SUBCONTRACTOR/CONSULTANT ADDRESS CITY/STATE/ZIP <br />LICENSE 4..%•••• C-57 C-61 0-09 Other NUMBER i° I 15'IFS/ EXPIRATION DATE ell /3 (V2 C'73 <br />BILLING PARTY: OWNER CONTRACTOR SUBCONTRACTOR/CONSULTANT <br />DOMESTIC WELL SAMPUNG: . General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic (4393) <br />INTENDED Use Domestic/PrivattNe Irrigation/Agricultural Industrial Water Quality Monitoring Soil Sampling/Characterization <br />Public Water System <br />If Oferent from Owner: Water System Name Contact Name or Phone Number <br />TYPE OF WORKMF NEW Well Replacement Well Well Alteration/Modification Other <br />Monitoring Well(s) ft of wells r- Soil Boring(s) A of bonngs Geotechnical A of honngs <br />Out-Of-Service Well L Out-Of-Service Well Renewal Cross-Connection Repair <br />New Pump Pump Replacement 0 Pump Repair . Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method <br />Proposed Well <br />Well Casing <br />Grout Seal <br />Depth 6.00 ft 4Ixcavation / 6 in diameter NoOpen Bottom <br />Diame en / (z. in Thickness/Gauge/ASTM Schad : Steel Plastic <br />Depth ft Neat Cement (94 lb bag/5-10 gal water) ....NPSand Cement <br />Condulpr Casing .7- in diameter / Conductor Casing,Depth 5 <br />Mud Rotary Air Rotary . Auger Ny Cable Tool Push Point Other <br />2—S a V <br />Gravel Pack/Gravel Size in diameter <br />ft <br />Stainless,Steel Other <br />/0. 3 sack mix/7 gal water <br />Bentonite (20% solids) Other <br />Grout Placement MethoN Pumped Free Fall Other Retardant / Accelerator (name) <br />PEDESTAL Installed By Driller Pump Contractor Other <br />in Christy Box Stove Pipe ft Thick Concrete Pedestal Dimensions: Width ft Length <br />ft Pump Set ft Standing Water Level Submersible Turbine Other HP PUMP <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 WITH ALL <br />WORKERS COMPENSATION LAWS. <br /> <br />,21Pol 48 HOUR AD E NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />--Cr it TITLE 65-2 DATE SIGNED <br />OWNER NAME