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_Zur' SIGNED <br />gtINIT • - <br />Soil Boring Inspegn By <br />COMMENTS <br />Date Constructed Well Depth ft <br />/ aq o _ <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 <br />JOB ADDRESS 0 I <br />CROSS STREET <br />OWNER NAME <br />CONTRACTOR <br />OWNER ADDRESS _i_SEA pzirk Drziike. <br />—aie ti r;tii <br />t.3 N 1.41--ozo-z7- PARCEL SIZE a ,s--LAND USE APPLICATIONS <br />LI <br />www.sjgy.orgiehd EXPIRES 1 YEAR FROM DATE ISSUED <br />1.1/1 0 (TZ LIC • CI Yi7JP <br />wyt 0 uei rd o <br />* CONTRACTOR ADDRESS IOWA SAcr . Atlf <br />SU.1.107A. CrM.'/CONSULTANT Oed AL" 440)4/e INA c <br />SUBel<CONSULTANT ADDRESS .51MiA4kttt___ <br />LICENSE g C-57 C-61 D-09 Other NUMSE <br /> PHONE <br />CITY/STATE/ZIP 146K49 CO. C4 q C3 36 <br />PHONE 116 S ZA0 <br />CITY/STATE/ZIP 1?-46e (4. 4;60 <br />PHONE tei - Lee 17. 12214._ <br />CITY/STATE/ZIP 603/1 <br />/ <br /> CA q4&-a0 <br />1 a EXPIRATION DATE <br />BILLING PARTY: OWNER CONTRACTOR XSUBCONTRACTORJCONSULTANT <br />DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) - Dibromochloropropane (4392) Arsenic (4393) <br />INTENDED USE .. Domestic/Private Irrigation/Agricuttural Industrial Water Quality Monitoring Moil Sampling/Characterization <br />Public Water System <br />ltd/learnt from Owner. Water System Name Contact Name or Phone Number <br />TYPE OF WORK New Well Replacement Well Well AlteraSon/Modtfication Other <br />Monitoring Well(s) # of wells Soil Boring(s) <br />Out-Of-Service Well <br />Geotechniml ti of btmnes <br />Out-Of-Service Well Renewal Cross-Conn ction Repair <br />New Pump Pump Replacement Pump Repair Raise Well Casing <br />WEIL Coesrsucnos <br />Drilling Method • Mud Rotary Air Rotary )(Auger tiable Tool Push Point Other <br />Proposed Well Depth 50 ft Excavation In diameter Open Bottom . Gravel Pack/Gravel Size in diameter <br />5- <br />Cot Wove <br />Well Casing <br />Grout Seal <br />Conductor Casing in diameter / Conductor Casing Depth <br />Diameter in Thickness/Gauge/ASTM Schad Steel <br />Depth f-s- -0 ft X Neat Cement (94 lb bag/5-10 gal water) <br />ft <br />Plastic Stainless Steel Other <br />Sand Cement sack mix/7 gal water <br />Bentonite (20% solids) ' Other <br />Grout Placement Method Pumped Free Fall Other Tee ww C. Retardant / Accelerator (name) <br />PEDESTAL Installed By --- Driller Pump Contractor Other <br />- Concrete Pedestal Dimensions: Width ft Length ft Thick in Christy Box ' Stove Pipe <br />Submersible Turbine Other HP Pump Set ft Standing Water Level ft <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPUCATION 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 />E NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br /> TITLE RME DATE Oct., 5, 2021 <br />AH-6 <br /> HE.,4 <br />DEPARTMENT USE ONLY <br /> <br />Application Accepted By L- Date 10/7ja Area 3/Lm PI/ 1°1:Employee ID# AS <br /> <br />Grout Inspection By Date toVA.V..1/4 SPECIAL Well Permit <br />' <br /> <br />Pump Inspection By Date WAIVER Received <br />PE <br />Codes <br />SC <br />Info <br />Received <br />Eyet, <br />Checlal <br />,Cash <br />Amount <br />RemItt, <br />Permit/ Date I Invoice I Well ID* <br />1.137(2 15-0 aiW. W54- *I 001 I <br />,,luest <br />U. '2- <br />, 1 <br />END 43-06 6:11/20IS <br />dexi: /327647782 4/3286618S <br /> WELL PUMP peruirt