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JOB ADDRESS -*'" (.4(, cirazip "rz*ty r 79/ <br />CROSS STREET ICA 6-,z4v-ril /2.1.7 APN 2(1 -08e -.310-12('VARCEL. SIZE F3-3 LAND USE <br />OWNER NAME /114, gey <br />OWNER ADDRESS 74/70 1.4/A- kt C.- 4 LA/P / 516- /02,0 <br />CONTRACTOR 4/41-1- /3" c — KA4.1t- /115 00A-rej <br />CONTRACTOR ADDRESS ject.) I/0 4. i 4-L Pt //I" <br />SUBCONTRACTOR <br />PHONE <br />crryisTATEap tvr- ArtvGetef ,C3f 9.00e, <br />PHONE(If) 3 71-/Y 3Y <br />crryisTATEIzip (4.101' 540-4-416.1.„ 'Jill <br />PHONE <br />SUBCONTRACTOR ADDRESS <br /> <br />C FTYIS TATE/21P <br /> <br />LICENSE XC-57 C-61 D-09 - Other NUMBER ?...17 Vt / EXPIRATION DATE 2/706,/ <br /> PAYMENT <br /> -RECEIVED <br />MAR 1 8 2019 <br />AN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />8EAe1m DEPARTMENT <br />- 4 <br />.4/ <br />sk <br /> <br />Application Accepted By Cate <br /> <br />Grout Inspection By Date <br /> <br />Pump Inspection By Date <br /> <br />Soil Boring Inspection By Date <br />COMMENTS <br />Area Employee ID# <br />PEC AL Well Permit <br />WAIVER Received <br />Constructed Well Depth ft <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT CALL (209) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) - Dibromochloropropane (4392) Arsenic (4393) <br />INTENDED USE Domestic/Private - Irrigation/Agricultural Industrial _ Water Quality Monitoring '7(Soil Sampling/Characterization <br />Public Water System <br />If different from Owner: Water System Name Contact Name or Phone Number <br />TYPE OF WORK New Well Replacement Well Well Alteration/M-Alfication Other <br /> :SS32100V 3.1.15 Monitoring Well(s) # of well! toil Boring(s) #of borngs X,_Geotechnical / -C of t'""gs <br />Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair <br />New Pump Pump Replacement Pump Repair Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method Mud Rotary Air Rotary XAuger . Cable Tool Push Point Other <br />Proposed Well Depth 2C., ft Excavation re) in diameter _ Open Bottom Gravel Pack/Gravel Size in diameter <br />Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched - Steel Plastic Stainless Steel Other <br />Grout Seal Depth ft ›ir.,eat Cement (94 lb bag/5-10 gal water) Sand Cement sack mixl7 gal water <br />Bentonite (20% solids) - Other <br />Grout Placement Method Pumped?cFree Fall Other - Retardant / Accelerator (name) <br />PEDESTAL Installed By Driller Pump Contractor Other <br />Concrete Pedestal Dimensions: Width ft Length <br /> <br />ft Thick in Christy Box Stove Pipe <br /> <br />PUMP Submersible Turbine - Other HP Pump Set ft Standing Water Level ft <br /> <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 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-769 <br />SIGNED •isq-c4.-4 TITLE r 19PF DATE 3,1i 11. <br />PE <br />Codes <br />SC <br />Info Ca <br />Received Checidt/ Amount <br />- emitted Date Permit/ <br />Service Re. ues # Invoice, .... Well ID# <br />IC411 <br />i <br />Air a I .i i lj il i I le 0 .1. 4... I , ' 0 i ikii. <br />' r Ex_pir <br />END 43-06 revised 4/14/18 WELL /PUMP PERMIT