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Vi CONTRACTOR n SUBCONTRACTOR/CONSULTANT 11 OWNER <br />SIGNED <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 />MINIMUM 48 „.,5 H R ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7,697 <br /> TITLE ) 6 r Lk7 rii 2-K DATE <br />_14 <br />614A/ <br />( -e <br />Soil Boring Inspection <br />COMMENTS Hid/ Ci <br />Grout Inspection By Date 0 SPECIAL Well Permit <br />Pump Inspection By Date /n WAIVER Received <br /> Date 6/14 Di-.97_.-1 Constructed Well Depth ft <br />- tre des 41 s, giver <br />0,0At4:011131g EHD 43-06 6/11/2019 WELL /PUMP PERMIT <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - SrocKToN CA 95205 -6232 (209) 468-3420 <br />NON-REFuNDABLE PERMIT www.sjgov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS <br />CROSS STREET'Ho 11- R APN 90 100 'PARCEL SIZE 3, iit t LAND USE APPLICATION # <br />PHONE <br />CONTRACTOR ADDRESS 22o 1 A1c,4.r Rol 56e 10 0 CITY/STATE/ZIP <br />SUBCONTRACTOR/CONSULTANT - E Ss La rotc,o-- Etlio Koh <br />SUBCONTRACTOR/CONSULTANT ADDRESS -hp Ad&fris S CITY/STATE/ZIP <br />C-57 _1 C-61 1_1 D-09 u Other NUMBER CI gq 7-4, 7 <br />DOMESTIC WELL SAMPLING: o General Mineral/Coliform Bacteria (4391) o Dibromochloropropane (4392) Arsenic (4393) <br />TYPE OF WORK J New Well U Replacement Well u Well Alteration/Modification U Other <br />n Monitoring Well(s) # of wells fl Soil Boring(s) S of borings ndl Geotechnical S of borings <br />0 Out-Of-Service Well 0 Out-Of-Service Well Renewal 0 Cross-Connection Repair <br />O New Munn n Pumn Rrinlaripment n Puma Reoeir Li Raise Well Casino <br />U Sand Cement sack mix/7 gal water <br />PEDESTAL Installed By 0 Driller c Pump Contractor C Other <br />Li Concrete Pedestal :Dimensions: Width ft Length ft Thick in 0 Christy Box C Stove Pipe <br />Pump Set ft Standing Water Level ft HP PUMP -1 Submersible fl Turbine n Other <br />WELL CONSTRUCTION <br />Drilling Method Na( Mud Rotary _1 Air Rotary u Auger L Cable Tool 'Push Point <br />Proposed Well Depth S0-150 ft Excavation in diameter 0 Open <br />Conductor Casing in diameter / Conductor Casing Depth <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched U Steel <br />Grout Seal Depth SO" ft 1,1 Neat Cement (94 lb bag/5-10 gal water) <br />Bentonite (20% solids) 7 Other <br />Grout Placement Method 'Pumped I I Free Fall ii Other Retardant / Accelerator (name) <br />U Other <br />Bottom 0 Gravel Pack/Gravel Size in diameter <br />ft <br />U Plastic u Stainless Steel LI Other <br />DEPARTMENT S ONLY <br />/2) Application Accepted By Date / / Area Employee ID# As <br />PE <br />Codes <br />SC <br />Info <br />Received <br />By <br />Checidll <br />Cash <br />Amount <br />Remitted Date Permit/ <br />SerWce Rawest # Invoice # Well ID# <br />43-7,9 iso <br />u,076. <br />vi64 p ipa I- fl-if Id e 00 LI kw ik <br />I <br />OWNER NAME Orli Dr Ric ;'(IL Cam p4 <br />CITY/STATE/ZIP <br />CONTRACTOR <br />LICENSE <br />BILLING PARTY: <br />OWNER ADDRESS )14 Dovilels sT 5 hp I(Dtio <br />kik-ik4e,1 tr. <br />0 jrJ 9C' s out; Reiell- ciTymis R"),Opy 9s3 CC. <br />Ormilu. I NC Ti7q <br />PHONE .94 cl - 131 / s- <br />s+oc-It.hpi c A- 9 S- Z.06 <br />&IQ ) -icz-q <br />c-AVis'6 10 <br />PHONE <br />EXPIRATION DATE :SS3LICIOV 311S INTENDED USE Li Domestic/Private 7 Irrigation/Agricultural c Industrial C Water Quality Monitoring 4 Soil Sampling/Characterization <br />U Public Water System <br />If different from Owner Water System Name Contact Name or Phone Number