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SPECIAL Well Permit <br />WAIVER Received <br />Constructed Well Depth <br />Employee ID# Area <br />ft <br />Kiqcj <br />N*12 \ 0$2`62P1 WELL /PUMP PERMIT END 43-06 6/11/2019 <br />in diameter <br />'Mud Rotary E Air Rotary 0 Auger CI Cable Tool E Push Point E Other <br />Depth_ __ft Excavation in diameter CI Open Bottom E Gravel Pack/Gravel Size <br />Conductor Casing in diameter / Conductor Casing Depth ft <br />in Thickness/Gauge/ASTM Sched <br />sack mix/7 gal water 0 Neat Cement (94 lb bag/5-10 gal water) Ll Sand Cement <br />El Other <br />CONTRACTOR PHONE <br />PHONE <br />CITY/STATE/ZIP <br />CONTRACTOR ADDRESS CITY/STATE/ZIP <br />SUBCONTRACTOR/CONSULTANT <br />SUBCONTRACTOR/CONSULTANT ADDRESS <br />I CONTRACTOR LI SUBCONTRACTOR/CONSULTANT BILLING PARTY: I I OWNER <br />If different from Owner: Water System Name Contact Name or Phone Number <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.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br />DOMESTIC WELL SAMPLING: _ General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic (4393) <br />>(Domestic/Private 0 Irrigation/Agricultural 0 Industrial E Water Quality Monitoring <br />Public Water System <br />E Soil Sampling/Characterization INTENDED USE <br />JOB ADDRESS -0 0 `A-t\-e—:::)\—-C>,S-\— V- CITY/ZIP 'A-Nc c <br />CROSS STREET St"-tS4)11 APN a 9 (517 ODg PARCEL SIZE 0 <br />OWNER NAME <br />OWNER ADDRESS <br />LAND USE APPLICATION # <br />PHONE fi1(&)51 e_, 2_0 vtA1,3\rovv\c_.)7 1,,Ahs-„(vie__\ 2rivtikvoA <br />CITY/STATE/ZIP <br /> cic-)'2Dck I <br />LICENSE CI C-57 0 C-61 C D-09 E Other NUMBER EXPIRATION DATE <br />Diamete <br />Depth ft <br />Bentonite (20% solids) <br />REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7617 <br />TITLE OW DATE ta (o2NA \ <br />pcSubmersible 0 Turbine E Other HP .3 Pump Set SO ft Standing Water Level '24:) 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 />MirlI <br />t./ <br />UM 48 HOU VANCE <br />TYPE OF WORK NevirWelr U Replacement Well <br />Monitoring Well(s) # of wells <br />Out-Of-Service Well <br />,I<New Pump 0 Pump Replacement <br />Well Alteration/Modification 0 Other <br />O Soil Boring(s) # of borings <br />Out-Of-Service Well Renewal <br />Pump Repair <br /># Geotechnical of borings <br />Cross-Connection Repair <br />Raise Well Casing <br />Plastic E Stainless Steel E Other Steel <br />Retardant / Accelerator (name) Grout Placement Method IT-Pumped 0 Free Fall 0 Other <br />WELL CONSTRUCTION <br />Drilling Methot <br />Proposed Well <br />Well Casing <br />Grout Seal <br />PEDESTAL Installed By U Driller 0 Pump Contractor CI Other <br />Concrete Pedestal 0Dimensions: Width ft Length ft Thick Ij in II Christy Box 0 Stove Pipe <br />.1 <br />PUMP :SS3UCIOV 311S sow 2 32021 <br />HEAE, to <br />4Q1,11N c <br />liolv4s. °wiry .414 ab_.0.44.47.417A4 ,. <br />DEPARTMENT USE ONLY <br /> <br />Application Accepted By Z-- Date -1V42 4//ii / <br /> <br />Grout Inspection By Date <br /> <br />Pump Inspection By AlfcsAt '!iSto Date 31;\1,e1-‘ <br /> <br />Soil Boring Inspection By Date <br />COMMENTS niet,) ;den kwooLi 0 (log <br />PE <br />Codes <br />SC <br />Info <br />Received <br />By / _ <br />Check#/ <br />Cash <br />Amount <br />Remitted Date / <br />Permit/ Invoice # Well ID# <br />li g ° 0 S eA/07-6 Vi 5 ii- , 4 I 9-1124 <br />Service Reau;sit4 q00/-ht" <br />41 (71 <br />-0" ( p- PA)/ nirkistr ce,v6