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D Retardant / Accelerator (name) Grout Placement Method 0 Pumped Free Fall Other <br />ft Thick <br />PEDESTAL <br />in C Christy Box 0 Stove Pipe <br />Installed By 0 Driller U Pump Contractor 0 Other <br />0 Concrete Pedestal 0 Dimensions: Width ft Length <br />TYPE OF WORK C New Well 0 Replacement Well 0 Well Alteration/Modification 0 Other <br />O Monitoring Well(s) If of wells C Soil Boring(s) 501 borings E Geotechnical # of borings <br />0 Out-Of-Service Well 0 Out-Of-Service Well Renewal 0 Cross-Connection Repair <br />o New Pump X.Pump Replacement 0 Pump Repair U Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method 0 Mud Rotary 0 Air Rotary 0 Auger D Cable Tool 3 Push Point D Other <br />Proposed Well Depth ft Excavation in diameter 0 Open Bottom <br />0 Conductor Casing in diameter / Conductor Casing Depth <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched 0 Steel <br />Grout Seal Depth ft 0 Neat Cement (94 lb bag/5-10 gal water) <br />0 Bentonite (20% solids) D Other <br />0 Gravel Pack/Gravel Size <br /> ft <br />0 Plastic 0 Stainless Steel 0 Other <br />0 Sand Cement sack mix/7 gal water <br />in diameter <br />I HEREBY CER I Y 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 />MIN <br />SIGNED <br />.}c Submersible° Turbine Other <br />01,14=E REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 95-7697,9 yek <br />TITLE 0.11ti€A"-- DATE 7 .7 77y /V4k. ttp Air 7)- 410-4;14 <br />it) c <br />EAti- <br />PUMP HP A Pump Set ft Standing Water Level ft <br />CONTRACTOR <br />0 ,tv ore <br />ocq i<(& (24 <br />lAbovnia (1,44--v <br />CONTRACTOR ADDRESS CP (C) Lk) 1 kr fir fa,c4 <br />PHONE SUBCONTRACTOR/CONSULTANT <br />NON-REFUNDABLE PERMIT <br />- 0 <br />d,991g <br /> <br />PARCEL SIZE 0-.7 'Sg LAND USE APPLICATION # <br />PHONE 570 - 1-17 <br />ESCaierk CA- 9 .53,:)./7 CITY/STATE/ZIP <br />WiS PHONE (901 - <br />17)(14-11, (4 5 CITY/STATE/ZIP <br />.s• ov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS <br />CROSS STREET <br />OWNER NAME <br />OWNER ADDRESS <br />Crrylip <br />SUBCONTRACTOR/CONSULTANT ADDRESS <br />LICENSE *-57 0 C-61 0 D-09 0 Other NUMBER 1410Y00 <br />BILLING PARTY: 0 OWNER Ti CONTRACTOR 0 SUBCONTRACTOR/CONSULTANT <br />CITY/STATE/ZIP <br />EXPIRATION DATE 3//42, <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 -6232 (209)468-3420 <br />DOMESTIC WELL SAMPLING: 0 General Mineral/Coliform Bacteria (4391)0 Dibromochloropropane (4392)0 Arsenic (4393) <br />INTENDED USE kikomestic/Private 0 Irrigation/Agricultural 0 Industrial <br />0 Public Water System <br />Water System Name If different from Owner <br />0 Water Quality Monitoring U Soil Sampling/Characterization <br />Contact Name or Phone Number <br />DEPARTMENT USE 0 LY <br /> <br />Application Accepted By ----- Date 1 /dila ? Area Li/q g Employee ID# F V <br /> <br />Grout Inspection By Date 0 SPECIAL Well Permit <br /> <br />Pump Inspection By L., 1 1 ..: S tro CO•2v, at:. i_ Date 242_4 I-Lci.. I 0 WAIVER Received <br /> <br />Soil Boring Inspection By Date Constructed Well Depth ft <br />COMMENTS <br />PE <br />Codes <br />SC <br />Info <br />Received CICzelcglyptt/ Amount <br />_Remitted Date „ <br />Permit/ <br />Service Request # Invoice # Well ID# <br />1131C) C?:'"3 ii&--1&67 4-7 -7 (Wi l-, 1/16,1173 44 <br />EHD 43-06 6/112019 <br />60, 60 -0 vuereaci" <br /> WELL /PUMP PERMIT