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-57 LI C-61 rl D-09 IT Other NUMBER <br />SUBCONTRACTOR <br />SUBCONTRACTR ADDRESS <br />LICENSE <br />SIGNED <br />NCE NOTICE REQUIRED FOR IrpPECTIONS - PLEASE CALL (209) 99-797 <br />4 ./4Wee DATE TITLE <br />WELL/PUMP PERMIT <br />SAN.JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT <br />JOB ADDRESS (47 44! <br />CROSS STREE LAA 4A A. g <br />OWNER NAME <br />OWNER ADDRESS <br />CONTRACTOR <br />CA L (209) 953-7697 FOR INSPECTIONS <br />L <br />A P N te5(99"--100 <br />EXPIRES 1 YEAR FROM DATE ISSUED <br />Jill _At! CITY/ZIP <br />PARCEL SIZE( <br />CITY/STATE/ZIP <br />Fr 4.-lemt,S <br />CONTRACTOR ADDRESS 9/C90 0 I' <br />CITY/STATE/ZIP <br />PHONE <br />EXPIRATION DATE <br />441-9its"" <br />LAND USE APPLICATI N # :SS32100V 3.1.1S DOMESTIt WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392)1 Arsenic (4393) <br />INTENDED USE O Domestic/Private Li Irrigation/Agricultural 11 Industrial I I Water Quality Monitoring LI Soil Sampling/Characterization <br />II Public Water System <br />If different from Owner: Water System Name Contact Name or Phone Number <br />TYPE OF WORK <br />/Veto <br />WELL CONSTRUCTION <br />Drilling Method 0 Mud Rotary El Air Rotary E Auger 11 Cable Tool LI Push Point LI Other <br />Proposed Well Depth ft Excavation in diameter Li Open Bottom <br />El Conductor Casing <br />Well Casing <br />Grout Seal <br />Diameter in Thickness/Gauge/ASTM Sched 0 Steel 0 Plastic H Stainless Steel E Other <br />Depth ft E Neat Cement (94 lb bag/5-10 gal water) LI Sand Cement sack mix/7 gal water <br />Bentonite (20% solids) 0 Other <br />Grout Placement Method EI Pumped 0 Free Fall El Other <br /> <br />H Retardant / Accelerator (name) <br /> <br />PEDESTAL Installed By LI Driller 11 Pump Contractor LI Other <br />El Concrete Pedestal 0Dimensions: Width ft Length ft Thick in 0 Christy Box Li Stove Pipe <br />PUMP CI Submersible 0 Turbine U Other HP <br /> <br />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 COMPENSATION LAWS. <br />CI New Well E Replacement Well <br />onitoring Well(s) # of wells <br />Out-Of-Service Well <br />LI New Pump 0 Pump Replacement <br />in diameter / Conductor Casing Depth <br />PAYMpA/„. <br />Li Geotechnical <br />Out-Of-Service Well Renewal 0 Cross-Connection Repair <br />CI Pump Repair ri Raise Well Casing <br />Well Alteration/Modification 0 Other <br />Soil Boring(s) # of borings <br />841:20AQ/114:, <br />2018 <br />U Gravel Pack/Gravel <br /> ft <br />77.WRDOgyAREIVAgelvetelvr sigA H <br />T r <br />Asock' <br />7> <br />RTMENT U E ONLY <br />Date /2-- Z 2/((ff <br />) <br />Application Accepted By <br />Com/mar-45 Date <br /> <br />Pump Inspection By Date <br />Grout Inspection By <br /> <br />Soil Boring Inspection By Date <br />COMMENTS ()k-C. ELi <br />Area Employee ID#(Akviv <br />SPECIAL Well Permit <br />WAIVER Received <br />Constructed Well Depth ft <br />s <br />S (D cz.z‘,c\ <br />PE <br />odes <br />SC <br />Info <br />Received 4,e,.„7, <br />ash <br />Amount <br />emitted Date Permit/ <br />Service Request # Invoice # Well ID# <br />(7 R dt k5-7 as- (.),-- _ \-1,--k7-1i, WPOOlil 10 g <br />EHD 43-06 8/01/16 WELL /PUMP PERMIT