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Area sic/. <br /> <br />Employee 10# <br />SPECIAL Well Permit <br />WAIVER Received <br />Constructed Well Depth <br />pit <br />ski/ <br /> NAy 2 5 20210 <br />A s Nfo-4,44„. <br />HE,170RO" co <br />N4147.41Nry <br />ft <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.Sjgov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED R23 6.1,7 e Ad crraip <br />Ch Ple, APR PARCEI SIZE a • 36 LAND USE APPLICATION AI <br /> <br />p„..E _205 - c; - 0.2.2 <br />OWNER ADDRESS 1-1 7 LI /I foil; COt://nek --,/ C(TY/STATFJZIP /76 C. ,',.'4-i 0 blel ''..; e. Lei 1 <br />CONTRACTOR / /. V, /1 4/ Gt) e't refs LA // /.-)(,u//,,,2 PHONE ' <br />CONTRACTOR ADDRESS 1—/ 7 S--- OVA 17 giti CrrY/STATERJP /7 el ,...-ed (-,-,. 6-1S ,?e,f0 <br />SUBCONTRACTOR/CONSULTANT PHONE <br />SUBCONTRACTORJCONSULTANT ADDRESS Cm/STATE/LP <br />LICENSE /C-57 C-61 0-OR Other NUMBER /003.2q? EXPIRATION DATE /0 3/ --2/ <br />B1LUNG PARTY: I OWNER CONTRACTOR SUBCONTRACTORICONSULTANT <br />DOMESTIC WELL SAMPLING: XGeneral Mineral/Coliform Bacteria (4391)/ribromochloropropane (4392) Arsenic (4393) <br />INTENDED USE ....,tomesticiPrivate Irrigation,Agecultural Industnal F Water Quality Monitoring Soil Sampling/Characterization <br />Public Water System <br />If dIffernnt from Owner lbabo System Name Contact None or Phone Number <br />TYPE OF WORK ..‘„4siew Well - Replacement VVeII - Well Alteration/Modification Other <br />1 Monitoring Well(s) Slot wells 1 Soil Bonng(s) of bonrx, of hannos Geotechnical <br />1 Out-Of-Service Well 1 Out-Of-Service Well Renewal Cross-Connection Repair <br />1 New PuMD Pump Replacement 1 Pump Repair F Raise Well Casino <br />WELL CONSTRUCTION <br />Drilling Method/Mud Rotary I Air Rotary L Auger I Cable Tool I Push Point Other <br />Proposed Well Depth _260 ft Excavation 0 /Ain diameter - Open Bottom XGravel Pack/Gravel Size 3/Z in diameter <br />- Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter Z in Thickness/Gauge/ASTM Sched - Steel Plastic 1 Stainless Steel . Other <br />Grout Seal Depttgesi _ft - Neat Cement (94 lb bag/5-10 gal water) ?<Sand Cement / 0, 3 sack mix!7 gal water <br />- Bentonite (20% solids) - Other <br />Grout Placement Methodi(Pumped Free Fall Other , Retardant / Accelerator (narne) <br />PEDESTAL Installed By ADriller Pump Contractor ... Other <br /><Concrete Pedestal -Dimensions: Width > ft Length ft Thick it Christy Box Stove Plpe <br />PUMP .../S'ubmersibIe Turbine 7 Other HP Pump Set ft Standing Water Level ft <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 UCENSE 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 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />SIGNED TITLE c_77 c‘J t'"-- DATE < <br /> <br />r9 6 <br /> <br />JOB ADDRESS <br />CROSS STREET <br />OWNER NAME I e f e d /-7 <br />v-41) <br />‘.) <br />DEPARTMENT USE ONLY <br /> <br />Application Accepted By Date S/3 sh 1 <br /> <br />Grout Inspection By Date <br />Pump Inspection By AAgeres^11/2417 Date /C,377e/ <br />Soil Bonng Inspection By <br />COMMENTS 1513-C) <br />Date <br />r <br />PE <br />Codes <br />SC <br />Info <br />Received <br />B <br />(..C.teigieckifil(...j Amount <br />Remitted Date Permit/ <br />ervice Re uee If Invoice ii Well IDS <br />`1.3kz) a L-o 1 3#1e14 4/S. i‘i ) <br />1-13“, 20 <br />' i -T Lido : <br />9'.2 544 <br />I (to .9-0 -7 i <br />43c: ) , le i f is- o I I I <br />Li3401, pi I 4 73 1 IA It <br />[HO 43-06 6/1 v2019 WELL /PUMP PERNIT