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JOB ADDRESS '- C) 112 0 t' LI T1A A IN ? te‘ Ilea A, crryizip 1 f1/4 ii, Li; 1 e; 3 t.." 4- <br />CROSS STREET 1,0(")r Le iAry,411 k4i. AP N D S t; - 0.2-C - 1 4 PARCEL SIZE (1 8i hLAND USE APPLICATION # TI f(' 519 <br />OWNER NAME P(t 1T e_ e ii T e { p e 1 1:7 e ' ) , I: Ile- - PHONE ? el —S." ?) 2. <br />OWNER ADDRESS 3 el 40 N IN i ki RIL, k crryisTATEizip T It At 'y <br />CONTRACTOR NVA PHONE <br />CONTRACTOR ADDRESS Pt if <br />SUBCONTRACTOR/CONSULTANT /VC th fne-e././i /II r ,IN PHONE 2c1- 2 37. - 4c3 <br />SUBCONTRACTOR/CONSULTANT ADDRESS -11 e 1.44y, 4 2IAS-itTE/ZIP (sir, (1c <br />LICENSE sk C-57 H C-61 - 0-09 Other NUILBER 1(70 k.21,7 ,-15-- EXPIRATION DATE 0 / / <br />BILLING PARTY: 7 OWNER <br />CITY/STATE/ZIP <br />CONTRACTOR _ SUBCONTRACTOR/CONSULTANT <br />ft Thick <br />PEDESTAL <br />in = Christy Box I Stove Pipe <br />Installed By Ii Driller 0 Pump Contractor h Other <br />'7 Concrete Pedestal Dimensions: Width ft Length <br />HP Pump Set ft Standing Water Level PUMP ft Submersible 0 Turbine H Other <br />WELL CONSTRUCTION <br />Drilling Method Mud Rotary Air Rotary >Suger Cable Tool Push Point I Other <br />Proposed Well Depth '2 5- ft Excavation 6.0 ;New- in diameter -. Open Bottom C Gravel Pack/Gravel Size in diameter <br />0 Conductor Casing in diameter / Conductor Casing Depth ft <br />Diameter in ThicknessiGauge/ASTM Sched 7 Steel 0 Plastic 7 Stainless Steel I Other <br />fl Sand Cement sack mix/7 gal water <br />Well Casing <br />Grout Seal Depth ft A Neat Cement (94 lb bag/5-10 gal water) <br />7 Bentonite (20% solids) 7 Other <br />Grout Placement Method - Pumped A.Free Fall Other Retardant / Accelerator (name) <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - Srocio-oN CA 95205-6232 (209) 468-3420 <br />NON-REFUNDABLE PERMIT www.sjgov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br />DOMESTIC WELL SAMPLING: 1 General Mineral/Coliform Bacteria (4391) E Dibromochloropropane (4392) 1 Arsenic (4393) <br />INTENDED USE 7 Domestic./Private Irrigation/Agricultural I Industrial r: Water Quality Monitoring >CSoil Sampling/Characterization <br />7 Public Water System <br />If different from Owner Water System Name Contact Name or Phone Number <br />TYPE OF WORK 0 New Well 7 Replacement Well 7 Well Alteration/Modification Other <br />El Monitoring Well(s) 4 of wells 7 Soil Boring(s) # of borings XGeotechnical 44- It of bonngs <br />0 Out-Of-Service Well 0 Out-Of-Service Well Renewal Cross-Connection Repair <br />L New Pump ._ Pump Replacement u Pump Repair Raise Well Casing <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br />JOAQUIN COUNTY ORDINANC S, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br />CURRENT AND ACTIVE WIT OE Q4LIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WORKERS COMPEt‘SATION jWS. <br />MINI /18 140 CE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 954-N97 <br />SIGNED H 6 Trni DATE 43/V ( SS3UCIOV 31.1S NY\ <br />e_ <br />ft <br />DEPARTMENT USE ONLY <br /> <br />Application Accepted By 4. Date <br /> <br />Grout Inspection By Date <br /> <br />Pump Inspection By Date <br /> <br />Soil Boring Inspection By Date <br />COMMENTS <br />Area YC7 C7 <br />/I) c•-• <br />Employee 104 <br />I SPECIAL Well Permit <br />0 WAIVER Received <br />Constructed Well Depth <br />PE <br />Codas <br />SC <br />Info <br />Received l., hec Amount <br />Remitted D te Permit/ <br />Service Reouest # Invoice # Well ID# <br />as <br />LI 37.Z 1 S-0 A__ 376c7, i i ViVOLIK/19 <br />EHD 43-0€ 6/11/2019 WELL /PUMP PERMIT