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— <br /> <br />Af.a. <br /> <br />74-e Arovii/9,4o <br />z <br /> LIX <br />WC1-01/ <br />4C-1)—ri 4.74Q1dt4tc_1120 <br />Nev ._ RoAfj„,_. OUN <br />1" Oe473;74 <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 -6232 (209) 468-3420 <br />NON-REFUNDABLE PERMIT www.sjgov.ory/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS yfyz CITY/ZIP <br />4/4- RY/17'h at3A P N E 060 L) <br />PHONE <br />OWNER ADDRESS CITY/STATE/ZIP <br />CONTRACTOR <br /> <br />11//47‘&:7e G'__'L;11e PHONE 7 3 -5.z/47) <br />CONTRACTOR ADDRESS <br /> <br />CITY/STATE/ZIP <br />SUBCONTRACTOR/CONSULTANT PHONE <br />SUBCONTRACTOR/CONSULTANT ADDRESS CITY/STATE/ZIP <br />LICENSE AcC-57 0 C-61 0 D-09 0 Other NUMBER ki 1.1) 1,.11 ke EXPIRATION DATE <br />BILLING PARTY: <br />0 OWNER <br /> <br />0 CONTRACTOR 0 SUBCONTRACTOR/CONSULTANT <br />DOMESTIC WELL SAMPLING: 0 General Mineral/Coliform Bacteria (4391) 0 Dibromochloropropane (4392) 0 Arsenic (4393) <br />INTENDED USE ,›VDomestic/Private 0 Irrigation/Agricultural 0 Industrial 0 Water Quality Monitoring 13 Soil Sampling/Characterization <br />Public Water System <br />If different from Owner: Water System Name Contact Name or Phone Number <br />TYPE OF WORK 0 New Well 0 Replacement Well 0 Well Alteration/Modification 0 Other <br />Monitoring Well(s) # of wells 0 Soil Boring(s) # of borings 0 Geotechnical <br />Out-Of-Service Well 0 Out-Of-Service Well Renewal 0 Cross-Connection Repair <br />New Pump 0 Pump Replacement )i'Pump Repair atiEr:eiCi'e 0 Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method 0 Mud Rotary 0 Air Rotary 0 Auger 0 Cable Tool 0 Push Point 0 Other <br />Proposed Well Depth ft Excavation in diameter 0 Open Bottom 0 Gravel Pack/Gravel Size <br />Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched 0 Steel 0 Plastic 0 Stainless Steel 0 Other <br />Grout Seal Depth ft 0 Neat Cement (94 lb bag/5-10 gal water) Sand Cement sack mix/7 gal water <br />Bentonite (20% solids) 0 Other <br />Grout Placement Method 0 Pumped 0 Free Fall 0 Other 0 Retardant / Accelerator (name) <br />PEDESTAL Installed By 0 Driller 0 Pump Contractor 0 Other <br />Concrete Pedestal ODimensions: Width <br />ft Length <br />ft Thick <br /> <br />in 0 Christy Box 0 Stove Pipe <br />PUMP O Submersible 0 Turbine 0 Other HP <br />Pump Set ft Standing Water Level <br />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 CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATION LAWS. <br />SIGNED <br />87DVANCE NOTICE REQUIRED FOR IpPECTIONS - PLEASE CALL (209) 957697 <br /> T TLE DATE a / 7 0 <br />1 <br />TA? <br />) <br />DEPARTMENT USE ONLY .../ <br /> <br />Application Accepted By 2"--2---" Date /2/1/010 P17 Area d/9 Employee ID# f <br /> <br />Grout Inspection By Date 0 SPECIAL Well Permit <br />Pump Inspection By 4 r.AtA, l (C) Vt.', ts (Vii 11___ Date f t thgtA 0 WAIVER Received <br /> <br />Soil Boring Inspection By , Date Constructed Well Depth ft <br />COMMENTS PDIeEde/r %/011ie vJe 1 1 ‘(:',e:4 / fepaCP/41er4 <br />PE <br />Codes <br />SC <br />Info <br />Received cliar...kil <br />By Cash <br />Amount <br />Remitted Date Permit/ <br />Service Request # Invoice # Well ID# <br />LI3V- oco ilt01-40 47? 12.01.Lo wPoot-Ii4t5 <br />END 43-06 6111i2019 WELL /PUMP PERMIT <br />CROSS STREET <br />OWNER NAME /11,02/2 /1-- 6:0457Z. <br />PARCEL SIZE I LAND USE APPLICATION # :SS31:ICIUV BlIS # of borings <br />in diameter