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WELL CONSTRUCTION <br />Drilling Method > Mud Rotary : Air Rotary 0 Auger ,0 Cable Tool [ Push Point rl Other <br />Proposed Well Depth., 0 ° ft Excavation i.2- in diameter [7] Open Bottom )( Gravel Pack/Gravel Size In diameter <br /> <br />-[ Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter I. in Thickness/Gauge/ASTM Sched.. DR-2, ‘ : Steel )( Plastic E Stainless Steel <br /> <br />Other <br /> <br />Grout Seal Depth ‘ 0 0 ft -. Neat Cement (94/b bag/5-10 gal water) • Sand Cement sack mix(' gal water <br />X Bentonite (20% solids) IT Other <br />0 Retardant / Accelerator (name) Grout Placement Method 2 Pumped E Free Fall E Other <br />PEDESTAL Installed By i] Driller [ XPump Contractor Other <br />Concrete Pedestal EDIri ensions: Width ft Length <br /> <br />ft Thick Li Christy Box L Stove Plpe <br />PUMP Submersible:. Turbine L: Other HP Pump Set ft Standing Water Level ft <br />BILUNG PARTY: OWNER CONTRACTOR IT SUBCONTRACTOR/CONSULTANT <br />JOB ADDRESS <br />CROSS STREET <br />OWNER NAME <br />CONTRACTOR <br />BAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205-6232 (209) 468-3420 <br />NON-REFUNDABLE PERMIT www.sjgov.orgiehd EXPIRES t YEAR FROM DATE ISSUED <br />A 1- <br />OwNER AobREss I 2S- PY-OV cl -C. in <br />C (64 1 -e, J -t I IIt' LO <br />CONTRACTOR ADDRESS P C .(V)>C- (-1 <br />1 0 1 c-i F, Li v-e, 06-1v_ RA CirviZiP Loc.- 1 1 C2 Li 0 <br />14 4/ Fs,- A P N 0 (O ( Ci 0 ... PARCEL SIZE2 I 39 LAND USE APPLICATION # <br />C tf(- loc Pit.. C) PHONEI's, -(2,(4) 747 - .2 ot• 7 <br />CITY/STATE/ZIP Lo A 1 6.1 - - - - .2k-t D_ <br />PHONE 51.$)e) qt9r). 01 vc-i <br />CITY/STATE/ZIP R. 11./-2- hcA... in IC. C(S 3(157 <br />PHONE <br />CITY/STATE/ZIP <br />SUBCONTRACTOR/CONSULTANT ) <br />SUBCONTRACTOR/CONSULTANT ADDRESS <br />LICENSE (C-57 - 0-61 LI 0-09 1 Other NUMBER I 12I'LlLf 103 EXPIRATION DATE <br />WELL/PUMP PERMIT :SS3NOCIV 31IS DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391),k Dibromochloropropane (4392) Arsenic (4393) <br /> <br />INTENDED USE y Domestic/Private 0 Inigation/Agricultural E Industrial E Water Quality Monitonng E Soil Sampling/Characterization <br />Public Water System <br />If different from Owner' Water Systern Name Contact Name or Phone Number <br />TYPE OF WORK )(New Well Replacement Well 0 Well Alteration/Modification 2 Other <br />- Monitoring Well(s) # of wells 0 Soil Boring(s) *of borings Geotechnical *of tanngs <br />Out-Of-Service Well D Out-Of-Service Well Renewal 7 Cross-Connection Repair <br />New Pump [•.- Pump Replacement 0 Pump Repair Raise Well Casing <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 COMPUANCE WITH ALL <br />WORKERS COMP SATION LAWS. <br />'CE NOTICE REQUIRED FOR INSPOT,IONS -PLEASE CALL (209) 953-7697 <br /> TITLE 1:W' I "'"e. .1?-7 DATE Lp f 1 t,7 2.1Th SIGNED <br />MI MM 0 A <br /> <br />DEPARTMENT SE ONLY <br /> <br />Application Accepted By [r`r."-74.' /iv Date <br /> <br />Grout Inspection By 6.4 Date <br /> <br />Pump Inspection By Date <br /> <br />Soil Boring Inspection By Date <br />COMMENTS <br />jo '30 Area Employee I D# <br />I SPECIAL Well Permit <br />WAIVER Received <br />Constructed Well Depth <br />PE <br />Codes <br />SC <br />Info <br />Received Check* casv i Amount <br />Remitted , ate Permit! <br />Service 0 Invoice # Well ID0 <br />4 , I F 0 <br />B1 <br />ele14,0P-1- l' V42 0 irt kAil. . U <br />dc.1 <br />if <br />/1-- <br />4 145-- I f g, ianiL-4 3 <br />EHD 43-06 6/11/2019 WELL /PUMP PERMIT <br />/6 6.s-e.Y/z