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TITLE DATE 'SI/ <br />/5" <br />ri? <br />a /7617117 <br />—77 <br />1.71" <br />tarn <br />Application Accepted By <br />Grout Inspection By <br /> <br />Pump Inspection By ,A6A <br /> <br />Soil Boring Inspection By <br />COMMENTS Weil f ("/ (11 V/ 'POO %De <br />DEPARTMENT USIE ONLY <br /> Date dh /A)`; 1 Area I Employee ID# <br />0 SPECIAL Well Permk <br />WAIVER Received <br />Constructed Well Depth <br />FR <br />Date <br />Date 1-11-3 01-k <br />Date ft <br />OCi >7 <br />(Its j SIGNED <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - Sroocrou CA 95205 -6232 (209)4684420 <br />NON-REFUNDABLE PERMIT www.s ov.or eh _ <br />.., <br />JOB ADDRESS 17 S i../ 5 s . LA /A Nigi{ g 0 CiTY/Zie i n Ai C 95 .7 y 3 7 <br />CROSS STREET VGilpi0 APN V6.1 —05—(>/-11" PARCEL SIZE aS LAND USE APPLICATION # <br />OWNER NAME ..1 c 1.4 isi 1- t 1 Ls 0 F cirMS 1-41- PHONE at') Ci ieb .). 7,- 7tt 7 <br />OWNER ADDRESS 1 1 ii 5 _s. L A M Mgas II 0 CtrOSTATFJZIP Tn A CI CA q ti 3 7 7 <br />CONTRACTOR sELr PHONE <br />CONTRACTOR ADDRESS CRY/STATE/ZIP <br />SUBCONTRACTOR/CONSULTANT PHONE <br />SUBCONTRACTOR/CONSULTANT ADDRESS CRY/STATERJP <br />LICENSE Li C-57 7 C-61 L D-09 ul Other NUMBER EXPIRATION DATE <br />EULLING PARTY: )(OWNER 0 CONTRACTOR 0 SUBCONTRACTOR/CONSULTANT <br />DOMESTIC WELL SAMPLING: 0 General Minerat/Coliform Bacteria (4391) D Dibromochloropropane (4392) 0 Arsenic (4393) <br />INTENDED US 4 ItprIricestic/Private ] lnigation/Agricultural E Industrial 0 Water Quality Monitoring D Soil Sampling/Characterization <br />7 Public Water System <br />ff different from Owner Water System Name Contact Name or Phone Number <br />TYPE OF Woes 0 New Well 0 Replacement Well 0 Well Alteration/Modffication E Other <br />7 Monitoring Well(s) # of wells 17 Soil Boring(s) #01 borings 0 Geotechnical #01 borings <br />, Out-Of-Service Well it Out-Of-Service Well Renewal i 1 Cross-Connection Repair A <br />Lidfa; Pump Li Pump Replacement u Pump Repair Li Raise Well Casing <br />WELL CONSTRUCTION ' SAN <br />Drilling Methe4: ; • Mud Rotary 17 Air Rotary 0 Auger U Cable Tool r Push Point 0 Other EArv /14,04/ , <br />Proposed Well ,,opth It Excavation in diameter [7 Open Bottom 0 Gravel Pack/Gravel Size in diamdte/ I. <br />7 Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched 7 Steel 7 Plastic E Stainless Steel D Other <br />Grout Seal Depth ft ri Neat Cement (94 lb bag/5-10 gal water) -1 Sand Cement sack mix l7 gal water <br />1 Bentonite (20% solids) 7 Other <br />Grout Placement Method E Pumped Li Free Fall o Other [7 Retardant! Accelerator (name) <br />Other W N i• R [X' PEDESTAL Installed By 1 Driller i- Pump Contractrt <br />X Concrete Pedestal Dimensions: Width '(j' ft - Length ft Thick g in Li Christy Box D Stove Pipe <br />i <br />PUMP 'N4 Submersible Li Turbine CI Other HP 9s., Pump Set a.534.9 ft Standing Water Level I Cia 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 UCENSE IS <br />CURRENT AN • ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WORKERS C• E ATION LAWS. <br />PE <br />Codes <br />SC <br />Info <br />Received <br />By.n. <br />Checklf/ Amount <br />Remitted Date Permit/ Invoice # Well IDN <br />1-1380 0 3 i d,___e jzspovi . <br />1 I -Visa 910.21 <br />Sonia* Rtiquest it <br />vq1)01) Poll- <br />_ <br />X <br />END 43-06 6/11/2919 WELL /PUMP PERMfT