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%weorr Rec eivea <br />APR I <br />441v Jc1400 emmi N cou,, NEAL 0197‘tiv• appmb,_ rAt iwevr <br />2018 <br />RTMENW <br /> <br />Application Accepted By Date <br />E NLY <br />( Area A q7 Employee ID#04140 <br /> <br />Grout Inspection By Date Li SPE IAL Well Permit <br /> <br />Pump Inspection By Date LI WAIVER Received <br /> <br />Soil Boring Inspection By Date Constructed Well Depth <br />COMMENTS 0 M ' (1 . <br />EP <br />ft <br />PE <br />Codes <br />SC <br />Info <br />Received ec <br />ash <br />Amount <br />Remitted Date Permit/ <br />Service Request # Invoice # Well ID# <br />Ocif ra zIZ2- 377/ .72.- 'Imir wfiv)oxic,2_ <br />EHD 43-06 8/01/16 WELL /PUMP PERMIT <br />WELL/PUMP PERMIT <br />t AN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT CALL (209) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DAT ISSUED <br />JOB ADDRESS Z2100 J CITY/ZIP <br />f <br />tr-2- PARCEL SIZES7 14 LAND USE APPLICATION # CROSS STREET 72Pilv& <br />OWNER NAME 14/4-44mr, 474-akvv PHONE 7.0 74' 7/.0 3 Z <br />OWNER ADDRESS ?COO( j4 93 CITY/STATE/ZIP 7iecnciE 9.--06127 <br />CONTRACTOR 651\17171A- dAlit 1e0,110i 41/'fl3 )1 PHONE 2131c" &t 1 L(; ,/ -71 <br />CONTRACTOR ADDRESS g4M7'6, 6,121)4,0 c Cf2-- CITY/STATE/ZIP f\jtA ST-() , et 7S-S6' <br />SUBCONTRACTOR <br /> <br />PHONE <br />SUBCONTRACTOR ADDRESS <br /> <br />CITY/STATE/ZIP <br />LICENSE LI C-57 ri C-61 ri D-09 E Other CZ( NUMBER q'.3 t• LC1 EXPIRATION DATE <br />DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) I Arsenic (4393) <br />INTENDED USE 0 Domestic/Private D Irrigation/Agricultural LI Industrial LI Water Quality Monitoring LI Soil Sampling/Characterization <br />0 Public Water System <br />If different from Owner: Water System Name Contact Name or Phone Number <br />TYPE OF WORK E New Well E Replacement Well LI Well Alteration/Modification 0 Other <br />LI Monitoring Well(s) # of wells 0 Soil Boring(s) # of borings LI Geotechnical <br /> # of borings <br />L Out-Of-Service Well 1] Out-Of-Service Well Renewal Li Cross-Connection Repair <br />ew Pump E Pump Replacement LI Pump Repair Ei Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method LI Mud Rotary D Air Rotary E Auger L Cable Tool LI Push Point LI Other <br />Proposed Well Depth ft Excavation in diameter Li Open Bottom D Gravel Pack/Gravel Size in diameter <br />Conductor Casing in diameter / Conductor Casing Depth ft <br /> <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched LI Steel D Plastic 0 Stainless Steel LI Other <br />Grout Seal Depth ft El Neat Cement (94 lb bag/5-10 gal water) LI Sand Cement sack mix/7 gal water <br />El Bentonite (20% solids) LI Other <br />Grout Placement Method E Pumped Li Free Fall Li Other I Retardant / Accelerator (name) <br />PEDESTAL Installed By n Driller LI Pump Contractor Other <br />LI Concrete Pedestal I IDimensions: Width ft Length ft Thick in CI Christy Box D Stove Pipe <br />PUMP 171 Submersible LI Turbine El Other HP Pump Set ft Standing Water Level 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 LICENSE IS <br />CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENS_AILAWS. <br />MINIMUM UR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br /> <br />F TITLE ? ROt \ Cif Pt Allgo/2-- DATE Li 11( 2 <br /> 4 <br />SIGNED)( :SS3LICICIV 311S