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ft Thick <br />PEDESTAL <br />in CI Christy Box 0 Stove Pipe <br />Installed By 0 Driller 0 Pump Contractor 0 Other <br />CI Concrete Pedestal 0Dimensions: Width ft Length <br />El Submersible0 Turbine 0 Other HP PUMP Pump Set ft Standing Water Level ft <br />WELL CONSTRUCTION <br />Drilling Method 0 Mud Rotary 0 Air Rotary It-Auger 0 Cable Tool 0 Push Point 0 Other <br />Proposed Well Depth \ 6 ft Excavation in diameter C Open Bottom 0 Gravel Pack/Gravel Size <br /> <br />0 Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter in ThIckness/Gauge/ASTM Sched 0 Steel 0 Plastic 0 Stainless Steel 0 Other <br />Grout Seal Depth ft y-Neat Cement (94 lb bag/5-10 gal water) 0 Sand Cement <br />0 Bentonite (20% solids) 0 Other ..L vnecer CACOU4k4,110, <br />Grout Placement Method El Pumped *Free Fall tr KtherIcritrite VI CI Retardant / Accelerator (name) <br />in diameter <br />sack mixI7 gal water :SS3klaaV 1LIS 56ck1 <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 />JOB ADDRESS Lt. CD\04 kxu - -c6,1ket- 5-)Gree-k- c,,,z,p ckoa-koy. 1 cA ck52A1 <br />CROSS STREET 'VA A W1/41.kv% NO..bk ApN ‘2,1_41.0 —2.6 PARCEL SIZE2-.4...b1 LAND USE APPLICATION # <br />OWNER NAME leka YkOCA et, -c_oca_ - V \__, <br />IgoLA <br />PHONE <br />OWNER ADDRESS 115 \ ao vaTumok QN11) , 11.1Aite "CITY/STATE/ZIP (k01,C4 it\t, i CA- ckS66 <br />CONTRACTOR <br />\1 <br />\I X ‘.0 c-AV.trt, PHONE (2_0(0 AO11 -0o <br />CONTRACTOR ADDRESS \NY) ROVi"--Vklglit (..--(-1e. CITY/STATE/ZIP ik.00XAV 0, CA c152A C <br />SUBCONTRACTOR/CONSULTANT Vit.A.\\rat.e, 1(....,A\ A\ '4 II7ocicvlec, PHONE (b) b11- 143m <br />SUBCONTRACTOR/CONSULTANT ADDRESS 04C) 7_,,,A,161 /4-(40\ IN) Cm/Sim/ZIP kue5k- ovn-to, CA <br />NUMBER 7 VA 0 IA EXPIRATION DATE 41 01 Z-2. <br />BILLING PARTY: 7(OWNER D CONTRACTOR d SUBCONTRACTOR/CONSULTANT <br />DOMESTIC WELL SAMPLING: D General Mineral/Coliform Bacteria (4391) CI Dibromochloropropane (4392) 0 Arsenic (4393) <br />INTENDED USE 0 Domestic/Private 0 Irrigation/Agricultural -' Industrial 0 Water Quality Monitoring Soil Sampling/Characterization <br />0 Public Water System <br />If different from Owner: Water System Name Contact Name or Phone Number <br />TYPE OF WORK 0 New Well 0 Replacement Well 0 Well Alteration/Modification 0 Other <br />0 Monitoring Well(s) # of wells 0 Soil Boring(s) # of borings Geotechnical <br /> <br />ci <br /> <br />of borings <br />CI Out-Of-Service Well 0 Out-Of-Service Well Renewal 0 Cross-Connection Repair <br />0 New Pump 0 Pump Replacement 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 FOR4SIcnIONS - PLEASE CALL (209) 953-7697 <br />0 7AkkA <br />QJ— kThk <br />LICENSE C-57 0 C-61 0 D-09 C Other <br />SIGNED TITLE Ce -,,Aeer DATE I IA <br />C <br />PAYMENT <br />RECEIVED <br />JAN 2 9 2021 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br />Application Accepted By <br />Grout Inspection By <br />Pump Inspection By <br />Soil Boring Inspection By <br />COMMENTS <br />E AR MENT USE 0 LY <br />Date 14 2 Area <br />Date <br />Date <br />o 4"orVi <br />E.,F,loyee ID# <br />U SPECIAL Well Permit <br />U WAIVER Received <br />Date Constructed Well Depth ft <br />PE <br />Codes <br />SC <br />IntL4 4 <br />Received <br />B <br />Check#/ <br />Cash 44 <br />Amount <br />Remitted Data Permit/ Invoice # Well ID# <br />4-37-2. 1 .47 c) no bo /j,-72_ t-al.z] <br />, 4w/ice Requeibt <br />iNntosjo <br />EHD 43-06 6/110019 VVELL /PUMP PERMIT