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INTENDED USE Ktomestic/Private 0 Irrigation/Agricultural 0 Industrial 0 Water Quality Monitoring C Soil Sampling/Characterization <br />0 Public Water System <br />If different from Owner: Water System Name <br />TYPE OF WORK 0 New Well 0 Replacement Well <br />0 Monitoring Well(s) # of wells <br />0 Out-Of-Service Well <br />New Pump rPump Replacement <br />0 Well Alteration/Modification 0 Other <br />o Soil Boring(s) # of borings Geotechnical #01 borings <br />O Out-Of-Service Well Renewal 0 Cross-Connection Repair <br />0 Pump Repair 0 Raise Well Casing <br />sack mix17 gal water <br />WELL CONSTRUCTION <br />Drilling Method 0 Mud Rotary 0 Air Rotary 0 Auger 0 Cable Tool 0 Push Point 0 Other <br />Proposed Well Depth ft Excavation in diameter 0 Open Bottom 0 Gravel Pack/Gravel Size <br /> in diameter <br />0 Conductor Casing in diameter I 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 C Neat Cement (94 lb bag/5-10 gal water) 0 Sand Cement <br />0 Bentonite (20% solids) C Other <br />Grout Placement Method 0 Pumped 0 Free Fall 0 Other <br />MI <br />SIGNED <br />HP I Pump Set ft Standing Water Level ft <br />DOMESTIC WELL SAMPLING: 0 General Mineral/Coliform Bacteria (4391) _1 Dibromochloropropane (4392) E Arsenic (4393) <br />3 Retardant / Accelerator (name) <br />ft Thick in 0 Christy Box U Stove Pipe <br />Installed By 0 Driller "3 Pump Contractor 0 Other <br />0 Concrete Pedestal 0 Dimensions: Width ft Length <br />PEDESTAL <br />PUMP <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 />CE NOTICE REQUIRED FORyPECTIONS - PLEASE CALL (209) 953797 <br />TITLE DATE <br />5/„Submersible 0 Turbine 0 Other <br />Contact Name or Phone Number <br />Area I /61 CI Employee ID# F 12_ <br />SPECIAL Well Permit :ssatiaciy B.LIS WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE -STOCK"l'ON CA 95205 -6232 (209)468-3420 <br />XPI E 1 YEAR FRI:475;2DATE,I.SSUED NON-REFUNDABLE PERMIT www.sjgov.orgiehd <br />JOB ADDRESS t \ CO 9 el L. WAN- .c _vase( g-c1; <br />---- <br />CITY/ZIP Y <br />CROSS STREET .--)G,t. k Tor, e APN i A ID6 (--)() 6 PARCEL SIZE '9 C7 LAND USE APPLICATION # <br />OWNER NAME Vn_ t -‘c-q-30 CL .Z--u ''t n ,PpNE ,IC' - 1/603 -‘5'39. <br />OWNER ADDRESS \ \ tO S 1:-: • q .)\&'"t-- \ VOCk. vpc c,,,,sTATEthp s___I-D fia), ( .71 15 0 L5- <br />CONTRACTOR I-A oui nnctn_ u0oLi-eiv SA SVA(-S I, n c.: 6,i_ET )0' 4117 <br />4'131 <br />CONTRACTOR ADDRESS C:9 I (-) l.....AD 't.ox, k" (-.4 CITY/STATE/ZIP CD -10( ri ), (14- 95-o <br />SUBCONTRACTOR/CONSULTANT PHONE <br />SUBCONTRACTOR/CONSULTANT ADDRESS CITY/STATE/ZIP <br />LICENSE it C-57 0 C-61 0 D-09 0 Other NUMBER 14(9,57C9 47 EXPIRATION DATE 3i/d404 <br />BILLING PARTY: 0 OWNER <br /> 'Of-CONTRACTOR C SUBCONTRACTOR/CONSULTANT <br />Neciipo <br />4-8 0 3 26; <br />44/vz.,Jo,4Qui.. couivry <br />--voo,v47, 7:41. <br />it44' CZ3,474fEiv <br />C-4 <br />.4111 <br />1 4Fi <br /> a <br />Application Accepted By <br />Grout Inspection By Date <br />Pump Inspection By tr cvq..151.1.0 (5 .4 ..r tn d, At : L. Date 2 t344 (1.174, I o WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth <br />COMMENTS <br />PE <br />Codes <br />SC <br />Info <br />Received ( , Check) Amount <br />Remitted i 1 Date Permit/ <br />grv'ce Request # Invoice # Well ID# <br />Cfgh <br />44381 oso /b /6//5/ 4;77 1-plil tt 1 V 00441-ei_ <br />EH D 43-06 6/11f2019 <br /> WELL /PUMP PERMIT <br />DEPARTMENT USE ONLY <br />Date ?/ <br />ft