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JOB ADDRESS <br />CROSS STREET <br />OWNER NAME <br />• /2 A 144 <br />. 4 APN e <br />re, 4 A / <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - S-rocicroN CA 95205 -6232 (209)468-3420 <br />NON-REFUNDABLE ERMIT www.sjgov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br />CITY/ZIP &er_1697 CA) 95,R/5— <br />PARCEL SIZE / LAND USE APPLICATION # <br />PHONEc9036P-57:60 <br />CONTRACTOR ADDRESS Zizo WI lay /20.v-,( <br />"Ii4-0-azi7121ts 100E14 gq-4)-1- <br />4631 Chei-atet eoacl <br />rz0 PHONE za3, <br />crrysTATElz,p9Ze4277_(,,,a goxs- <br />CITY/STATE/ZIP SM:11211(44 95:9716" <br />27/ D <br /> PHONE Zcq-s-/la? <br />cirasTATE2, <br />Other NUMBER 1/60FEI 41i' EXPIRATION DATE <br />CONTRACTOR SUBCONTRACTOR/CONSULTANT <br />DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic (4393) <br />INTENDED USE )<Qomestic/Private Irrigation/Agricultural Industrial Water Quality Monitoring Soil Sampling/Characterization <br />Public Water System <br />If different from Owner Water System Name Contact Name or Phone Number <br />TYPE OF WORK )(NeW Well Replacement Well Well Alteration/Modification Other <br />Monitoring Well(s) # of wells Soil Boring(s) S ot borings Geotechnical A of borings <br />Out-Of-Service Well I Out-Of-Service Well Renewal Cross-Connection Repair <br />Agew Pump Pump Replacement Pump Repair _ Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method )4 Mud Rotary Air Rotary Auger . Cable Tool - Push Point Other <br />Proposed Well Depth 60 ft Excavation j I in diameter I Open Bottom ,Gravel Pack/Gravel Size in diameter <br />ctoi;Cai <br />sg <br />Casing in diameter sch /Ceod ft Conductor Casing Depth Conductor n <br />Well Casing Thickness/G <br />/A <br />Steel ,Plastic Stainless Steel Other Diameter <br />Grout Seal Depth /0C) ft Neat Cement (94/b bag/5-10 gal water) Sand Cement sack mix/7 gal water <br />Bentonite (20% solids) : Other <br />Grout Placement Method 7:Pumped Free Fall Other Retardant / Accelerator (name) <br />PEDESTAL Installed By Driller )Pump Contractor Other <br /> <br />Concrete Pedestal Dimensions: Width €9 ft Length fC-T---=:)__-1flck in Christy Box <br /> <br />- Stove Pipe <br /> <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 COMPENSATII LAWS. <br />MINIMUM OUR ADV <br />SIGNED <br />OWNER ADDRESS <br />CONTRACTOR <br />SUBCONTRACTOR/CONSULTANTliTh <br />SUBCONTRACTOR/CONSULTANT ADDRESS <br />LICENSE ki/C-57 <br /> C-61 <br />BILLING PARTY: <br /> <br />OWNER <br />D-09 <br />>c Submersible: : Turbine I Other HP Pump Set ti 0 ft Standing Water Level "is— ft <br />OTICE REQUIRED FOR 11),SPECTIONS - PLEASE CALL (209) 953-7697 <br /> TITLE dr)" tj DATE :SSRIOCIV 311S A-rcka-wo <br />rro <br />EP TMENT U E •NLY <br />Application Accepted B <br />Grout Inspection By <br />Employee ID# <br />PECIAL Well Permit <br />WAIVER Received <br />Date Cortructed Well Depth 2. 1-3 <br />Area Date <br />Date <br />Pump Inspection By Date <br />Soil Boring Inspection By <br />COMMENTS 0 ...,,erle-CA4Z41 a4 ICo-1 ( 04- <br />ft <br />PE <br />Codes _ <br />SC <br />12fo <br />Received LIPS.kit4/ Amount <br />emitted <br />Permit' <br />Service Reque st...4( Invoice # Well ID# <br />P71 I 30 <br />al(3570 1 ciCashs6, rte <br />Lle 12'1 IV fa.) Li WI <br />it II <br />g et ite06-- 10 1t I/ <br />END 43-06 61112015 WELL /PUMP PERMIT