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END 43-06 6/111201111 WELL /PUMP PERMIT <br />WELL/PUMP PERMIT :SSMJCIOV 311S PUMP )(Submersible 0 Turbine 0 Other HP n.2 Pump Set ft Standing Water Level <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 />—v—........______ 'r-t 1al <br /> <br />Application Accepted By Date Area Employee ID# <br /> <br />Grout Inspection By Date 0 SPECIAL Well Permit <br />Pump Inspection By 21110:2 3ajall, Date 5 \ 11 lz-1 \ 0 WAIVER Received <br /> <br />Soil Boring Inspection By Date Constructed Well Depth ft <br />COMMENTS •••.r....9 twit- ..,-c-43 5 ç in/F-4.4_, ‘ i—p.4.) 0a=y2,D. <br />MINI WQI 48 HOUR DVANCE NOTICE REQUIRED FOR 17FECTI9NS - PLEASE CALL (209) 953-7697 <br />TILE 1"4". DATE 3- 21- <br />ft <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />PAYMENT <br />RECEIVED <br />MAR 2 2 2021 <br />CITY/STATE/ZIP SUBCONTRACTOR/CONSULTANT ADDRESS <br />CROSS STREET Lou‘se Ave. APN .., PARCEL SIZE <br />OWNER NAME Esinics. <br />OVYNER ADDRESS V a'Soxv (ea() <br />CONTRACTOR <br />CONTRACTOR ADDRESS aiao <br />SUBCONTRACTOR/CONSULTANT <br />LICENSE )4C-57 0 C-61 0 0-09 0 Other NUMBER Lihng, <br />BILLING PARTY: 0 OWNER XCONTRACTOR 0 SUBCONTRACTOR/CONSULTANT <br />1-Aovrma.n y•-)culex Skisims <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 -6232 (209)468-3420 <br />NON-REFUNDABLE PERMIT wwwjgov.orgiehd EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS (475--e, 0 Avs.fic, R <br />LAND USE APPLICATION # <br />Crrv/Zip <br />PHONE .209 - o6 - .Y.29 7 <br />karilctca, C/4 F53.3k) CITY/STATE/ZIP <br />PHONE (909- 53)-3alo <br />CITY/STATE/ZIP ft6 k_i— C 9,5;)15 - <br />PHONE <br />EXPIRATION DATE <br />IJJ <br />9 <br />SIGNED <br />DOMESTIC WELL SAMPLING: 0 General Minerat/Coliform Bacteria (4391) 0 Dibromochloropropane (4392) 0 Arsenic (4393) <br />TYPE OF WORK 0 New Well 0 Replacement Well 0 Well Alteration/Modification 0 Other <br />C Monitoring Well(s) # of wells 0 Soil Boring(s) tt of borings Geotechnical #01 borings <br />0 Out-Of-Service Well 0 Out-Of-Service Well Renewal U Cross-Connection Repair <br />0 New Pump ump Replacement 0 Pump Repair 0 Raise Well Casing <br />0 Push Point 0 Other <br />WELL CONSTRUCTION <br />Drilling Method 0 Mud Rotary 0 Air Rotary 0 Auger 0 Cable Tool <br />C Retardant / Accelerator (name) Grout Placement Method 0 Pumped 0 Free Fall 0 Other <br />ft Thick <br />PEDESTAL <br />in 0 Christy Box C Stove Pipe <br />Installed By 0 Driller 0 Pump Contractor 0 Other <br />0 Concrete Pedestal 0Dimensions: Width ft Length <br /> <br />Proposed Well Depth ft Excavation in diameter 0 Open Bottom 0 Gravel Pack/Gravel Size in diameter <br />0 Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched 0 Steel 0 Plastic 0 Stainless Steel 0 Other <br /> <br />Grout Seal Depth ft 0 Neat Cement (94 lb bag/5-10 gal water) 0 Sand Cement sack mhd7 gal water <br />C Bentonite (20% solids) 0 Other <br />7/n'\ <br />ARTMENT USE ØNLY <br />—06 <br /> CENIED <br /> AR 22 2021 <br />PE SC <br />Info <br />Received Checka/ <br />/ Cash <br />Amount <br />Remitted Date A <br />Permit/ <br />Swim Reque4 At Invoice a Well IDtt <br />.0dtst 071) Mik 0 Si 4 T7 .511.11 WOO ON <br />INTENDED USE Domestic/Private 0 Irrigation/Agricultural 0 Industrial 0 Water Quality Monitoring 0 Soil Sampling/Characterization <br />Public Water System <br />Water System Name Contact Name or Phone Number If different from Owner