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DEPARTMENT USE ONLY <br />Application Accepted By L. Date Sikiej <br />Employee ID/ :903L100V MLIS WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - Sroctcrotir CA 95205 -6232 (209)468-3420 <br />NON-REFUNDABLE PERMIT www.sjgov.orgiehd EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS . Il 5 .< 7)R \k) • r,riv4),,,e, V.,C)C• CiTv/Z1F Tr c, 1 953 09 <br />CROSS STREET AC)U.\ 52." ?, CAA APN OC\ \ el 0 3 PARCEL SIZE CN PIC LAND USE/APPLICATION* <br />OWNER NAME .So.ra.j. ,-- -\P HONE ii,ItiocNE 7 A_ct09 cif-ri -9 s:13 <br />OWNER ADDRESS I. LP ') 7\1. Arbole, &c,_ r.--,...,-,L, <br />CONTRACTOR Pump 'N Water, Inc. dba Dickey's Pump Service PHONE 209-394-3112 <br />CONTRACTOR ADDRESS PO Box 325 <br />cirdsrAluzip Atwater CA 95301 <br />SUBCONTRACTOR/CONSULTANT <br />PHONE <br />SUBCONTRACTOR/CONSULTANT ADDRESS <br />CITY/STATE/ZIP <br />LICENSE 0 C-57 0 C-61 00-09 0 OtherC 10 & D21 NUMBER 1001842 EXPIRATION DATE 3-31-2021 <br />BILUNG PARTY: _I OWNER <br /> <br />CONTRACTOR 0 SUBCONTRACTOR/CONSULTANT <br />DomEsTic WELL SAMPUNG: IJ General Mineral/Coliform Bacteria (4391): Dibromochloropropane (4392)11 Arsenic (4393) <br />INTENDED U$C. C Domestic/Private Orrigation/Agricultural C Industrial ' Water Quality Monitoring C Soil Sampling/Characterization <br />0 Public Water System <br />II different Corn Owner: Water System Name Contact Name or Phone Number <br />TYPE OF WORK 1: New Well :1 Replacement Well <br /> 0, Well Alteration/Modification 0 Other <br />0 Monitoring Well(s) # of wells C Sall Boring(s) of borings Geotechnical <br /> * of botings <br />C Out-Of-Service Well El Out-Of-Service Well Renewal C Cross-Connection Repair <br />V New Pump 0 Pump Replacement Cl Pump Repair 0 Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method 0 Mud Rotary Air Rotary Auger 0 Cable Tool 0: Push Point E Other <br />Proposed Well Depth ft Excavation in diameter n Open Bottom C Gravel Pack/Gravel Size In diameter <br />Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched 0 Steel -1 Plastic 1: Stainless Steel c Other <br />Grout Seal Depth ft • Neat Cement (94 lb b09/5-10 gal wafer) C Sand Cement sack mix/7 gal water <br />0 Bentonite (20% sotids) Ti Other <br />Grout Placement Method C Pumped C3 Free Fall C Other Cl Retardant /Accelerator (name) <br />PrnF?TAL Installed By 0 Driller N'Pump Contractor, 0 Other <br />P.' Concrete Pedestal :Dimensions: WIdth 0 fl Length 6 ft Thick 1 2 in Cl Christy Box 0 Stove Pipe <br />PUMP 0 SubmersibleCi/Turbine 0 Other HP 1 25 Pump Set_31AL ft Standing Water Level 85 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 COMPUANCE WITH ALL <br />WORKERS COMPENSATION LAWS. <br />MiNIMUM 43 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS • PLEASE CALL (209) 953-7697 <br />CFO DATE 1 1 -1 8-2020 SIGNED <br />• <br /> <br />Grout Inspection By Date <br /> <br />Pump Inspection By (& AtI ji Ax• Date 'LI '14:1 ?‘-'1-ck <br /> <br />Soil Boring Inspection By Date <br />COMMENTS Aer: V 4,i- i ••-k r 1,4 f <br />C SPECIAL Well Permit <br />0 WAIVER Received <br />Constructed Well Depth ft <br />PE <br />Codes <br />SC <br />Into <br />Received <br />B <br />ChecloY/ <br />Ar'esh <br />Amount <br />Remitted i Date Permit/ <br />Swrice, Reguest # , Invoice # Well ID# <br />... . <br />Vi..Sa- -- $ ) :._,/ 11P1.1 iilui tt 41 Lilif 1 <br />, <br />EHO 43-0e 6/11/2011) <br /> <br />4fr //7a32-H-4 <br /> WELL /PUMP PERMIT