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sack mixl7 gal water <br />WELL CONSTRUCTION <br />Drilling Method Mud Rotary Air Rotary Auger Cable Tool Push Point Other <br />Proposed Well Depth ft Excavation in diameter Open Bottom Gravel Pack/Gravel Size in diameter <br /> <br />Conductor Casing in diameter 1 Conductor Casing Depth ft <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched I Steel I Plastic Stainless Steel Other <br />Grout Seal Depth ft Neat Cement (94/b bag/5-10 gal water) Sand Cement <br />Bentonite (20% solids) Other <br />Grout Placement Method Pumped Free Fall Other <br />• -1 <br />cr <br />c <br />-41 <br />-J 1— <br />I I -12k. Oa. IAA.) <br />Grout Inspection By Date <br />Pump Inspection By act15iita•i:L02 Date <br />WELL /PUMP PERMIT END 43-06 611/2019 /27 // -7D <br />2..cito3ck 5 V ,vv.\ crryrzip JOB ADDRESS <br />OWNER NAME \ A <br />OWNER ADDRESS 71 3 As; Cx`il V._ y; Ala) eSied /..51?)--7 CITY/STATE2IP <br />PHONE 2-61 .5 .3 -5-0-2=2- <br />CONTRACTOR <br />CONTRACTOR ADDRESS <br />SUBCONTRACTOR/CONSULTANT <br />SUBCONTRACTOR/CONSULTANT ADDRESS <br />PHONE <br />CITYISTATEIZIP <br />PHONE <br />CITY/STATE/ZIP <br />NUMBER LICENSE C-57 C-61 D-09 Other EXPIRATION DATE <br />BILLING PARTY: OWNER CONTRACTOR SUBCONTRACTOR/CONSULTANT <br />If different from Owner. Water System Name Contact Name or Phone Number <br />Replacement Well TYPE OF WORK .New Well Well Alteration/Modification • Other <br />Monitoring Well(s) # of wells Soil Boring(s) # of borings Geotechnical ti of borings <br />-- Out-Of-Service Welt - Out-Of-Service Well Renewal - Cross-Connection Repair <br />New Pump Pump Replacement - Pump Repair Raise Well Casing <br />Retardant / Accelerator (name) <br />Christy Box Stove Pipe <br />PEDESTAL Installed By Driller Pump Contractor •._ Other CuJeiti.r <br /> <br />Concrete Pedestal _Dimensions: Width 5 ft Length ft Thick Ia <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE STOCKTON CA 95205 -6232 (209) 468-3420 <br />NON-REFUNDABLE PERMIT WWW.Sjg ov.o rg/eh d EXPIRES 1 YEAR FROM DATE ISSUED <br />DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic (4393) <br />PUMP )4( Submersible Turbine Other HP 10 Pump Set 112.- ft Standing Water Level 55 ft <br />CROSS STREET Hon CAr N-cAr APN 1? .7- YoC - PARCEL SIZE 10.01 LAND USE APPLICATION # <br />INTENDED USE 7+. Domestic/Private ),Irrigation/Agricultural Industrial Water Quality Monitoring _ Soil Sampling/Characterization <br />Public Water System <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 />MINIMU:_v,1(8 you DVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953 -7697 <br />TITLE (-)'—'" el*" DATE <br />DEPARTMENT USE ONLY <br />Date Area V C/ Employee 113# (L' <br />SIGNED <br />Application Accepted By <br />Soil Boring Inspectior‘By <br />COMMENTS ipik I 1 D <br />Data <br />PE <br />Codes <br />SC <br />Info <br />Received Checicif/ <br />JIR,Remitted (Cash <br />Amount Date Permit/ Invoice If Well ID'S <br />1 SPECIAL Well Permit <br />WAIVER Received <br />Constructed Well Depth ft <br />1cr —Dc) :SS380CIV 311S