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JOB ADDRESS <br />r ,!) A) <br />1.'4101 <br />4 r dy? <br />CITY/ZIP <br />CROSS STREET AA /Wnari-At.liVaig-0,-.A3. 1 ARCEL SIZE Yr;+/ LAND USE APPUCATION # . ,1 <br />OWNER NAME .5 f5 ITIrS 47F- Atri:Z407" 772 epx.isr744/7•04,15,0N. 9/G -752> 5----9 , <br />, e dye 0,....fR ADDRESS 73 I /ex/ -r<...frilhoc) /2-if:) c'rry' IsTATErzip . 6 - "inr74,017kiz, 4,1 <br />CONTRACTOR eV/44 1/4// 11-77---- ys PHONE'? 11-?"W 9'5778 <br />CONTRACTOR ADDRESS ) *2,' PI// /-----'_a---,--' itcn-yis-rATErzlp 1/ 41 95-7 . <br />SUBCONTRACTOR/CONSULTANT /' 's 4212.1:41. - - , 46 25 PHONE ""--- <br />SUBCONTRACTOR/CONSULTANT ADDRESS CITY/STATE/Zip . <br />LICENSE 20C-57 -6l D-09 , Other NUMBER ef"Sie, EXPIRATION DATE //4//'t ,t <br />BILLING PARTY: OWNER : CONTRACTOR ! SUBCONTRACTORICONSULTANT <br />0 <br />DOMESTIC WELL SAMPLING: I i General MIneral/Coliform Bacteria (4391) i Dibromochloropropane (4392) ' Arsenic (4393) <br />INTENDED USE Irrigation/Agricultural Industrial Water Quality Monitoring • Soil Sampling/Characterization ...kbomestic/Private <br />l'It1/4 ; Public Water System <br />If different from Owner: Water System Name Contact Name or Phone Number %% IA, i <br />' v ' do, TYPE OF WORK New Well XReplacement Well I Well Alteration/Modification Other <br />1 Monitoring Well(s) 4 of wells Soil Boring(s) 401 borings i Geotechnical 90 bot44j 7.., ." TO <br />I Out-Of-Service Well Out-Of-Service Well Renewal 1 Cross-Connection Repair PI ti• <br />Pump :.. Pump Replacement ,...i Pump Repair , : Raise Well Unlit. _)(New <br />WELL CONSTRUCTION <br />Drilling MethodAiNud Rota , r Rotary Auger : , Cre Tool Push Point i Other <br />Proposed Well Depth Excavation /2 In diameter , Open Bottom Pack/Graver Size //, $01' in diameter (.....10Eravel <br />; Conductoi Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter V in Thickness/Gauge/ASTM Sthed Ci--7127 Steel I Stainless Steel i Other ...LisOlastIc <br />Grout Seal Depth /pp ft i Neat Cement (94 lb bag/5-10 gal water) Sand Cement sack mix/7 gal water <br />entonite (20% solids) • I Other <br />Grout Placement Method . Pumped i Free Fat • Other Retardant /Accelerator (name) <br />PEOEsTAL Installed By H Driller P Pump Contractor - i Other <br />Concrete Pedestal _. Dimensions: Wdth ft Length ft Thick in Christy Box . Stove Pipe <br />RuMP ubmersible. Turbine Other HP ,S) Pump Set /.2e ft Standing Water Level 46 7.:11 gSalICIOV allS DEPARTMENT USE, ONLY <br />Date L7 2 0° Area <br />Date <br />Dates <br />Date <br />O t /hq /F-e) <br />Employee ID# mi <br />SPECIAL Well Permit <br />WAIVER Received <br />Constructed Well Depth <br />Application Accepted By <br />Grout Inspection By <br />Pump Inspection By <br />Soil Boring Inspection By <br />COMMENTS tk) [-TT- A L.. 671f2A,Ci <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.S OV.0r /ehd EXPIRES 1 YEAR FROM DATE ISSUED <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 S <br />MINI <br />SIG <br />111111111.11.1 111111I <br />41111111111111 ; <br />P 1,11,711MM <br />ir • <br />itIIIIIMIMPPIMMEMMMM ow <br />NOTICE REQUIRED FOR OSPECTIONS - PLEASE CALL (209) 953-7697 <br />TITLE.47 DATE 3MWD <br />r <br />47ENWRISMIL FAII _________ 1111WiritrilliMplIWM <br />MI IN 071.11A <br />PE <br />Codes <br />SC <br />Into <br />Received C.-C.114)&144,2a Amount <br />Remitted le Permit/ <br />Service Request 4 Invoice # Wall ID# -Cilh- <br />4391 .(, SINS- ll-l) <br />14 3q02 <br />700‘ <br />, _./,7_,It i, 70 tBcg Igo 17/7 ‘,OD ''1,20 Wc?00 1-kOle'n -1380 oso ' j/,4' 4 )S? Avo noLvouseQ <br />EHD 43-08 8/1112015 WELL /PUMP PERMIT