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PUMP HP Submersible 0 Turbine 0 Other Pump Set ft Standing Water Level ft <br />SIGNED <br />MINIMUM 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br /> TITLE 46' 146-4411- ("*.$4-(tee..,-(-er--- DATE 2- 7 — 2 ( <br />Area <br /> <br />Employee ID# F k 0/9/Q Application Accepted By Date <br />/2-N_LI2JP71 EHD 43-06 6/11/2019 WELL /PUMP PERMIT <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 2 tJa I cQ <br />CROSS STREET 4Di -/.01 APN Oi DLI 311 <br />OWNER NAME 12_ )4a P-IcL i t3G-IC <br />OWNER ADDRESS Z75— i/(-) pd( <br />CONTRACTOR "4A,/P-,t .5.ek (‘C. <br />CONTRACTOR ADDRESS 57/a 14 <br />SUBCONTRACTOR/CONSULTANT <br /> CITY/ZIP 74 0 Ir II 0 e5-" <br />PARCEL SIZE 0 6 LAND USE APPLICATION # <br />PHONE ?7? 7Y3 <br />CITY/STATE/ZIP T 4,b1 <br /> <br />PHONE --'ngrit ;C) 3:2 s 5:57 <br />CITY/STATE/ZIP SI/ockhk, CA- ?sr-0 ( <br />PHONE <br />CITY/STATE/ZIP SUBCONTRACTOR/CONSULTANT ADDRESS <br />LICENSE U C-57 cCC-61 U D-09 E Other NUMBER /0 Y.C. es?/ EXPIRATION DATE A.9- 3 / - <br />TYPE OF WORK II New Well 0 Replacement Well ‘ Well Alteration/Modification 0 Other <br />Monitoring Well(s) # of wells LI Soil Boring(s) # of borings 0 Geotechnical <br />Out-Of-Service Well E Out-Of-Service Well Renewal El Cross-Connection Repair <br />New Pump El Pump Replacement X Pump Repair ° gL:15( vJel i A Raise Well Casing <br />WELL CONSTRUCTION CG!5 MC <br />_..) <br />Drilling Method 0 Mud Rotary E Air Rotary E Auger E Cable Tool 0 Push Point 0 Other <br />Proposed Well Depth ft Excavation in diameter E Open Bottom 0 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 0 Plastic E Stainless Steel LI Other <br />Grout Seal Depth ft 0 Neat Cement (94 lb bag/5-10 gal water) 0 Sand Cement sack mix/7 gal water <br />Bentonite (20% solids) 0 Other <br />Grout Placement Method 0 Pumped 0 Free Fall 0 Other 0 Retardant / Accelerator (name) <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 />DEPARTMENT USE ONLY <br /> <br />Grout Inspection By Date E SPECIAL Well Permit <br />0 WAIVER Received <br /> <br />Soil Boring In§Rection By Date Constructed Well Depth ft <br />COMMENTS Ke, IS( we I I 115 J1 f ) ) 17 G refl9 pede sicl <br />PE <br />Codes <br />SC Received Check#/ <br />Cash <br />Amount <br />Remitted Date Permit/ <br />Service Request # Invoice # Well ID# <br />L'rc KL;-( °° <br />InfoBt 2 <br /> - 1e..ii-/-- 4' 7 7 20/94 WOW' US— <br />_ <br />Pump Inspection By4 ,)(.4 Date <br /># of borings :9932:100V 311S Installed By 0 Driller X Pump Contractor 0 Other <br />Concrete Pedestal ODimensions: Width '4 ft Length "--1 ft Thick (;-) in 0 Christy Box 0 Stove Pipe <br />PEDESTAL