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PHONE 20? 7y7 ?0o7 <br />JOB ADDRESS /0 757 C Ctsue 0--ic /24 cryizip od c 7-5-2 c/c) <br />CROSS STREET /-4,/ ee APN PARCEL SIZE LAND USE APPLICATION # <br />OWNER NAME r (0 K . o <br />SUBCONTRACTOR/CONSULTANT ADDRESS CITY/STATE/ZIP <br />CITY/STATE/ZIP CITY/STATE/ZIP 57/2 7.= (,-)e lark /2 <br />E Other LICENSE E C-57 XC-61 0 D-09 NUMBER ID w; 2 Cy EXPIRATION DATE /0- 17- 72 <br />SUBCONTRACTOR/CONSULTANT _1 OWNER CONTRACTOR BILLING PARTY: <br />CITY/STATE/ZIP 9s-e $i 2 <br />PHONE 7o2' 137,19 y <br />C/51- <br />PHONE <br />OWNER ADDRESS <br />CONTRACTOR <br />CONTRACTOR ADDRESS <br /> <br />/ 9 z 9 Prou: e We7 <br /> <br />iD4e I/ 40 V:1. )442 L_ <br />SUBCONTRACTOR/CONSULTANT A-.)0 C <br />)(Submersible E Turbine 0 Other HP 5 Pump Set to. 6 ft Standing Water Level / 20 ft PUMP <br />0 Plastic U Stainless Steel E Other <br />sack mix/7 gal water <br />Diameter in Thickness/Gauge/ASTM Sched E Steel <br />Depth ft 0 Neat Cement (94 lb bag/5-10 gal water) E Sand Cement <br />0 Bentonite (20% solids) CI Other <br />0 Retardant / Accelerator (name) Grout Placement Method 0 Pumped 0 Free Fall E Other <br />PEDESTAL Installed By E Driller 0 Pump Contractor CI Other <br />0 Concrete Pedestal El Dimensions: Width /0' ft Length /2, ft Thick 1' in E Christy Box E Stove Pipe <br />WELL CONSTRUCTION <br />Drilling Method <br />Proposed Well <br />Well Casing <br />Grout Seal <br />11 Mud Rotary LI Air Rotary CI Auger <br />Depth ft Excavation <br />CI Conductor Casing in diameter <br />E Cable Tool LI Push Point 0 Other <br />in diameter 0 Open Bottom 0 Gravel Pack/Gravel Size <br />/ Conductor Casing Depth ft <br />in diameter <br />-7 <br />PAYmovr <br />°EleetI/ED <br />i-k-b) 2 <br />SAN 2 2021 <br />QA.1,4 Atviit c „9_414.,,OUNly <br />Area LI / (V/ Employee ID# 12, <br />El SPECIAL Well Permit <br />0 WAIVER Received <br />Constructed Well Depth ft <br />F <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE -STOCKTON CA 95206-6232 (209)468-3420 <br />NON-REFUNDABLE PERMIT WWW.Sjgov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br />DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) 1 Dibromochloropropane (4392) Arsenic (4393) :SSMACICIV 311S INTENDED USE ,Domestic/Private 0 Irrigation/Agricultural CI Industrial E Water Quality Monitoring <br />CI Public Water System <br />If different from Owner: Water System Name <br />0 Soil Sampling/Characterization <br />Contact Name or Phone Number <br />TYPE OF WORK New Well U Replacement Well <br />0 Monitoring Well(s) # of wells <br />CI Out-Of-Service Well <br />New Pump LI Pump Replacement <br />E Well Alteration/Modification 0 Other <br />E Soil Boring(s) # of borings Geotechnical # of borings <br />0 Out-Of-Service Well Renewal El Cross-Connection Repair <br />CI Pump Repair 0 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 COMPLIANCE WITH ALL <br />WORKERS COMPENSATION LAWS. <br />MINIMUM 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />SIGNED TITLE ((got, -4-c c 6 DATE 2 - 2 - <br />DEPARTMENT USE ONLY <br /> <br />Application Accepted By ----- /./-- Date <br /> <br />Grout Inspection By Date <br /> <br />Pump Inspection By ..'t •rl (At r.) (Ci-,v-c.f.„ i 4 ,%.• 7_ Date 31 I/7 61i <br /> <br />Soil Boring Inspection By Date <br />COMMENTS vdP [1 \J FOr)L1 D g(X) <br />PE <br />Codes <br />SC <br />Info <br />Received <br />Ca. <br />Amount <br />Remitted Date Permit/ <br />Service Request # Invoice # Well ID# <br />LI;FO o::,-- ) buyt6 I , .-'" 1-1 :* V0010 WA, <br />EHD 43-06 6/11/2019 WELL /PUMP PERMIT