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SAN JOAOUIH COUNTY ENVIRONMENTAL HEALTH DEPARTMENT066 TON AVENUE-9TocKToN CA 96206 -6232 (20B) 468 420 <br />NON-REFUNDABLE PERMIT %VWW.slqay.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED.' <br />rl- 675 <br />JOBADDRESS o1- mZv' <br />CROSS STREET APN Ot T- 070-6 -PARS S¢E BLAND USEAPPLICATIONiR <br />OwNERNAME 44 n� l'IImo <br />r r� G�' (jam /� OWNER ADDRESS I �n')2.-1-. /� �� (J ��%i1 __y1f / �.�r*ISTATE/ZIP K. / , I <br />CONTRACTOR C 11 O f �(r� �� VA d G` (�T�-�-1 I �t 1 �' Y PHONE <br />y c� � a 5 CRY/STATErZP C - <br />CONTRACTOR ADDRESS - <br />SUBCONTRACTOR/CONSULTANT PHONE <br />SUSCONTRACfOR/CONSULTANT ADDRESS CRY/STATEMP 77 <br />(LICENSE XC -S7 ❑ C-61 ❑ D-09 ❑ Other NUMBER .dLA oLw EXPIRATION DATE <br />BILLING PARTY: ❑ OWNER D CONTRACTOR D SUBCONTRACTOR/CONSULTANT <br />DomEsnc WELL SAMPLING: ❑ General MineraVColiform Bacteria (4391) D; Dibromochloropropane (4392) O Arsenic (4393) <br />INTENDED USE XDomestic/Private D Irrigation/Agricultural D Industrial ❑ Water Quality Monitoring ❑ Sol Sampling/Characterization <br />D Public Water System <br />If d7Remnt from Ohner. Water System Nan* - Contad Nam or Phone Number <br />-TYPEOF1fORR U HewrYell U Reptacerrfeni VtleR U Y'lelf AteraUONW100 tabun U KXPW . <br />D Monitoring Wells) t of wells ❑ Soil Boring(s) 0 Of bourgs ❑ Geotechnical s d borings, <br />0 Cut-OfServi y� ❑ OUt-OfServioe Well Renewal ❑ Cross -Connection Repair <br />ew Pum - Ra laeement D Pump Repair " ❑ Raise Well Casing <br />WELL CONSTR ON <br />Drilling Method ❑ Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point D Other <br />Proposed Well Depth ft ESc8v3ti0n in diameter U Open Bottom U Gravel Pack/Gravel Size in diameter <br />D coodyc;ar CAsinCt- ,n Am=e cr / Co.*, -tor Cssio¢ r . A <br />Well Casing Diameter_ in Thickness/Gauge/ASTM Schad, ❑Steel ❑Plastic ❑Stainless Steel ❑Other <br />Grout Seal Depth ft ❑ Neat Cement (94 lb bag?s10 gel water) ❑ Sand Cement sack mbd7 gal water <br />❑ Bentonite (20% solids) ❑ Other <br />Grout Placement Method 0 Pumped ❑ Free Fall L ❑ Other D Retardant / Accelerator (name) <br />PEDESTAL Installed By ❑ Driller ❑ Pump Conti -actor ❑ Other <br />0 Concrete Pedestal ❑Dimenslons: Width ft Length ft Thick in ❑ Christy Box D Stove Pipe <br />BUMP )C -'AA err; ae❑ Twtoe ❑ Ofber HP <br />Pump Set � ft Sl�rvr SAtHn I I / {} <br />1 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 />� VFX <br />`' 0 2021 <br />p <br />V EN7,U� rY <br />A R T,19ENT <br />:LItrARTMENT USE r0NLY <br />Application Accepted�.,�Y,js?';,� ,/}r,J <br />—Date i � l si Area Ii 8 Em <br />Grout Inspection By i „ <br />ployee IDS <br />Pump Inspection By <br />Date ❑ SPECIAL Well Permit <br />Sou Li <br />Soonng Inspection By <br />Dam ❑ WAIVER Received <br />COMMENTS Date CorLstructed Well Depth tt <br />