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EHD 43-06 6/11/2019 WELL /PUMP PERMIT <br />Public Water System <br />If different from Owner: Water System Name <br />TYPE OF WORK _\lew Well ;<peplacement Well <br />E Monitoring Well(s) # of wells <br />Out-Of-Service Well <br />New Pump El Pump Replacement <br />Well Alteration/Modification 0 Other <br />0 Soil Boring(s) # of borings El Geotechnical <br />El Out-Of-Service Well Renewal 0 Cross-Connection Repair <br />Pump Repair El Raise Well Casing <br />',Submersible Li Turbine E Other I )/A... HP 6o ft Standing Water Level / 7 ft PUMP Pump Set <br />E Cable Tool 0 Push Point E Other <br />WELL CONSTRUCTION <br />Drilling Method, f Mud Rotary LI Air Rotary 0 Auger <br />Proposed Well Depth ft Excavation Ik in diameter 0 Open Bottom rGravel Pack/Gravel Size in diameter <br />PEDESTAL <br />in Li Christy Box 0 Stove Pipe <br />Installed By El Driller rump Contractor El Other <br />El Concrete Pedestal EDimensions: Width a- ft Length V-- ft Thick <br />Conductor Casing — in diameter / Conductor Casing Depth ft <br />Diameter 6 in Thickness/Gauge/ASTM Sched 9-00 Ci Steel plastic C Stainless Steel <br />Depth VO -1--- ft 0 Neat Cement (94 lb bag/5-10 gal water) ;$1 Sand Cement <br />Bentonite (20% solids) 0 Other <br />Grout Placement Method y Pumped 0 Free Fall 0 Other <br />Well Casing <br />Grout Seal <br />0 Retardant / Accelerator (name) <br />Li Other <br />sack mix/7 gal water <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 /># of borings <br />MINIM 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br /> TITLE (17/Aald44-4 DATE / //02 SIGNED <br />"fr <br /> i? 410 <br />ikor,, 4#047) <br />444,4- s2oph <br />A', ',1••• <br />4Z.7...1C <br />47 <br />Contact Name or Phone Number <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - SrocicroN CA 95205 -6232 (209) 468-3420 <br />DOMESTIC WELL SAmPLiNG:f General Mineral/Coliform Bacteria (4391) A1 Dibromochloropropane (4392) 01 Arsenic (4393) <br />INTENDED USE V,Dornestic/Private 0 Irrigation/Agricultural El Industrial 11 Water Quality Monitoring 0 Soil Sampling/Characterization <br />51 LA) -eno <br />CROSS STREW 6-r e 9ctic . APN 161 I (Th <br />ttuex- tiriMa e,}c)lius <br />OWNER ADDRESS TO Boy L-1-6 <br />V\ 00 vvyai40 Nor <br />CONTRACTOR ADDRESS 1/1 ZO Oil I Me <br />SUBCONTRACTOR/CONSULTANT Hrbei r) <br />SUBCONTRACTOR/CONSULTANT ADDRESS <br />LICENSE C-57 C-61 C D-09 <br />BILLING PARTY: 0 OWNER <br />JOB ADDRESS CITY/ZIP <br />OWNER NAME <br />CONTRACTOR <br />El Other NUMBER <br />0 CONTRACTOR Li SUBCONTRACTOR/CONSULTANT <br />.sjgov.orgiehd ,...___FXPIRES 1 YEAR FROM DATE ISSUED <br />lAmeM amyl cr) 61931, <br />pHoNEctl7c4.1-ig-i <br />ciTyisTATE,z,,0614, ROD5/Y4 <br />pHoNEabg_q5 <br />CITY/STATE/ZIP _ (fi 6752(C <br />PHONE nze) podot ,04 <br />EXPIRATION DATE öl <br />NON-REFUNDABLE PERMIT <br />PARCEL SIZE LAND USE APPLICATION # <br />DEPARTMENT USE ONLY <br />Application Accepted <br />Grcut Insptioil <br />Pump Inspection <br />Soil Boring Inspection <br />COMMENTSkJ er <br />jlt I <br />/ <br />34 ate <br />By <br />ISS ved r <br />u.) ( < <br />to'd rifprh a, e le( clu-IIVY Well it' f7115-7j77-14 py <br />6ii Cfc, tC/5 <br />By <br />By <br />By krAtt,5 cOCArt: <br />PE <br />Codes <br />SC <br />Info <br />Received <br />B A <br />CSig Vr#e Amount <br />Remitted ate Permit/ <br />Service Request # Invoice # Well ID# <br />i-Q OS / OR .-,,, j ,,O2Z-- 4./s-', 1/23._7/2DWT> 0 0 4 1 47 3 <br />L13-7 0 I 2 0 I -31-1,9,0 WP004-14-74 Li3ci I /7 IF <br />\i/ <br /># ISO WPC° 4- 1 4-7-3 <br />ti3gc?. 7/) 7o kis? 00+1 4-73 :SS3210C1V 211S Area "I 77 Employee ID# & <br />0 SPECIAL Well Permit <br />A. WAIVER Received <br />Constructed Well Depth ft <br />Date dc);9 <br />Date <br />Date 317 IV' <br />Date