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DEPARTMENT <br />USE PNLY <br />Application Accepted By '"��—L��f. Date _.>/W11111)I Area (Y�r I <br />Employee IDR <br />Grout Inspection By Date ❑ SPECIAL Well Permit <br />Pump Inspection By Date )( WAIVER Received <br />Soil Boring Inspection By Date Constructed Wall Depth ft <br />COMMENTS <br />l SAN JOAnUIN COUNTY WELVPU ���� ✓ �_ <br />ENmRONMENTALMP PERMIT <br />J <br />HEALTH DEPARTMENT <br />NON-REFUNDABLE PERMIT 1888 EAST HAZELTON <br />AVENUE - <br />CALL 2gTocrcTON CA 85206. (209) 488)420 <br />09 953-7697 FOR INSPECTIONS <br />JOB ADDRESS <br />/IA tEXPIRES 1 YEAR FROM DATE <br />ISSUED <br />p y� <br />CROaaBTREET VT I APNN 111-230-220 �m� PN�11 <br />/Q�, f,Au h 0 I <br />OWNER NAME ELIZIE LAND PARCS�• V '—' <br />O <br />USE APPUCAnON # <br />o <br />OWNER ADDRESS PHONE 1Od <br />CONTRACTOR -MAW I I S DF111 IN d I N �� CITY/STATEMP IDN <br />CONTRACTOR ADDREsa1 q f} 1j)ep,� Fl)• PHONE <br />SUBCONTRACTOR CRYlSTATEl7Jp D <br />SUBCONTRACTOR ADDRESS PHONE <br />LICENSE CRYlSTATFILP <br />G57 0 C�1 0 D-09 ❑ Other <br />0 <br />---_� NUMBER <br />J� <br />D�"tOZ� EJIPIRATON DATE -!N <br />DOMESTIC WELL SAMPuwny�Generel DA Bacteria <br />(4391) DlbromochlOropropans (4392) ❑ Arsenic (4393) <br />N U eatldPrivate ❑ (nigatlon/ABricultumt <br />❑ IndusMel <br />0 Public Water System D Water Quality Monitorin��.�11M, <br />II dirennl hom Oriwr. Wat.r sYetem Nemo <br />�Iclerizallon <br />TYPE OF WORN 0 New Well Replacement Well ❑ Well Alterotion/Modification <br />G Monitoring Wefl a ❑Other <br />( #ofweits G Soil0&b«inp, <br />G Out -Of -Service Well 0 Geotechnical awbatnpe <br />0 Out-OfService Well Renewal <br />❑ New Pum 0 PumnRe ac rmenl pj DCross-Connection Repair <br />AELL CO---`5}RU_ SON G Raise <br />Well Casin <br />Ddlliog MethodMud Rotary 0 Air Rotary 0 Auger 0 Cable Tool 0 Push Point ❑ Other <br />Proposed Well Depth If EXCBVagon 211 In diameter <br />❑ Open Bottom Gravel Pack/Gravel Size In diameter <br />Conductor <br />❑ Casing In diameter / Conductor Casing Depth g <br />Well Casing <br />Diameter,�U In Thlckness/Geuge/ASTM Schad 0 Steel O Plastic 0 Stainless Steel 0 Other <br />Grout Seal Depth !il/ I R ❑ Neat Cement (94 Ib beg�1_110 gel water)t Sand Cement k/ •3 sack mixl7 <br />gal water <br />❑ Benlonfte (20% solids) ❑ Other <br />Grout Placement Method X Pumped 0 Free Fall 0 Other 0 Retardant /Accelerator (name) <br />PEDESTAL Installed By D Driller 0 Pump Contractor ❑ Other <br />❑ Concrete Pedestal ODlmenslons: Width II Length fl Thick In ❑ Christy Box 0 Stove Pipe <br />PUMP 0 Submeralble0 Turbine D Other HP Pump Set ft Standing Water Level tl <br />1 HEREBY CERTIFY THAT 1 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. <br />I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br />CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN <br />WORKERS COMPENSATION LAWS. COMPLIANCE WITH ALL <br />DEPARTMENT <br />USE PNLY <br />Application Accepted By '"��—L��f. Date _.>/W11111)I Area (Y�r I <br />Employee IDR <br />Grout Inspection By Date ❑ SPECIAL Well Permit <br />Pump Inspection By Date )( WAIVER Received <br />Soil Boring Inspection By Date Constructed Wall Depth ft <br />COMMENTS <br />EHD43-m eovrn (/ <br />YI <br />G�7 168 <br />ELL!PUMP PERM(T <br />ejr7nu•i�va�'���� <br />EHD43-m eovrn (/ <br />YI <br />G�7 168 <br />ELL!PUMP PERM(T <br />