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If different from Owner: Water System Name Contact Name or Phone Number <br />0 Geotechnical # of borings # of borings # of wells 0 Soil Boring(s) Monitoring Well(s) <br />0 Raise Well Casing <br />Out-Of-Service Well <br />O Out-Of-Service Well Renewal 0 Cross-Connection Repair <br />New Pump 0 Pump Replacement 0 Pump Repair <br />TION <br />Mud Rotary 0 Air Rotary 0 Auger 0 Cable Tool 0 Push Point 0 Other <br />Depth ft Excavation in diameter 0 Open Bottom <br />in diameter <br />0 Gravel Pack/Gravel Size in diameter <br />/ Conductor Casing Depth ft <br />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 o Retardant / Accelerator (name) <br />Installed By 0 Driller 0125timp Contractor, 0 Other <br />Concrete Pedestal ODimensions: Width ft Length `5 ft Thick in 0 Christy Box C Stove Pipe <br />PEDESTAL <br />Area Employee ID# <br />EHD43-06 6/11/2019 WELL/PUMPPERMIT <br />CITY/STATE/Zip <br />NUMBER ,mLov,„ <br />0 SUBCONTRACTOR/CONSULTANT eCONTRACTOR BILLING PARTY: 0 OWNER <br />EXPIRATION DATE <br />PHONE i.- <br />-1'r 96- <br />PHONE nO(1 <br />OWNER NAME <br />I OWNER ADDRESS <br />CONTRACTOR j)Ctbk <br />CONTRACTOR ADDRESS <br />SUBCONTRACTOR/CONSULTANT <br />SUBCONTRACTOR/CONSULTANT ADDRESS <br />LICENSE 0 C-57 0 C-61 0 D-09 <br />CITY/STATE/ZIP <br />,Lth <br />Tod to- Kik-/CITY/STATE/ZIP <br />- LyX17 <br />P7t.' <br />PHONE <br />ELL/PU P PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - S-rocicrori CA 95205 -6232 (209) 468-3420 <br />NON-REFUNDABLE PERMIT WWW.Sjgov.orgiehd _EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS s_11 WA( )cmazip 95 -320 <br />CROSS STREET APN 2-0041 PARCEL SIZE 2- )LAND USE APPLICATION # <br />DOMESTIC WELL WELL SAMPLING: 0 General Mineral/Coliform Bacteria (4391) 0 Dibromochloropropane (4392) 0 Arsenic (4393) <br />Domestic/Private Irrigation/Agricultural 0 Industrial 0 Water Quality Monitoring 0 Soil Sampling/Characterization <br />Public Water System <br />TYPE OF WORK 0 New Well 0 Replacement Well 0 Well Alteration/Modification 0 Other <br />INTENDED USE :SS31.100V 311S Application Accepted By <br />Grout Inspection By <br />Pump Inspection By <br />Soil Boring Inspection By <br />COMMENTS 5-I2L' <br /> Date <br />Oo (-to if_ e pfrw <br />SPECIAL Well Permit <br />WAIVER Received <br />Constructed Well Depth ft <br />PE <br />Codes <br />SC <br />Info <br />Received <br />By . <br />cflekiW" <br />Cash <br />Amount <br />Remitted Date Permit/ <br />i Service Request # Invoice # Well ID# <br />4 201 (*) q fri4 t 2on-07 ,4) 2_ *(a-1 v000 iill-Lt <br />P RTMENT U <br />ei-1 Date? <br />Date Date <br />Date SH111:01 <br />in Thickness/Gauge/ASTM Sched 0 Steel 0 Plastic 0 Stainless Steel 0 Other <br />Conductor Casing <br />Diameter <br />Depth <br />WELL CONSTRU <br />Drilling Method <br />Proposed Well <br />Well Casing <br />Grout Seal