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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 -6232 (209)468-3420 <br />INTENDED USE Domestic/Private Irrigation/Agricultural Industrial Water Quality Monitoring Soil Sampling/Characterization <br />Water System Name <br />Public Water System <br />0 different horn Owner <br />PEDESTAL Installed By Driller Pump Contractor Other <br />Concrete Pedestal Dimensions: Width ft Length ft Thick Christy Box Stove Pipe <br />PUMP Submersible Turbine Other HP Pump Set ft Standing Water Level ft <br />ee red <br />ine; vi -61-4 Area Employee ID# <br />SPECIAL Well Permit <br />WAIVER Received <br />Constructed Well Depth ft <br />DEPARTMENT USE ONLY <br /> <br />Application Accepted By .-72. 1.,..,./...,... Date /0/./ 41/2 / <br /> <br />Grout Inspection By Date <br /> <br />Pump Inspection By Date <br /> <br />Soil Boring Inspection By Date A "Peo —li <br />COMMENTS <br />DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic (4393) <br />TYPE OF WORK - New Well Replacement Well • Well Alteration/Modification - Other <br />Monitoring Well(s) # of wells*Eroil Boring(s) 0 01 banngs 7C,Geotechnical Se". a at borings <br />Out-Of-Service Well - Out-Of-Service Well Renewal - Cross-Connection Repair <br />New Pump Pump Replacement Pump Renoir QAICP Wail Caninn <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 />NOTICE REQUIRED FOR (NSP,ECT IONS - PLEASE CALL t209) <br />TITLE RME DATE Oct. 6, 2021 <br />' <br />SIGNED <br />NON-REFUNDABLE PERMIT WWW.S ov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS 1.47S kJ qose,•,',1e CITY/ZIP 1.1" Cie, c <br />CROSS STREET <br />OWNER NAME <br />OWNER ADDRESS <br />CONTRACTOR <br />CONTRACTOR ADDRESS ID74k .CLerVI VI's" 4 • <br />SUllogidwArTOR/CONSULTANT 0, ,,...L ...., e.,,i,c_tiyu. ,... I T-4_ PHONE q49— 4535 <br />SUB3traACIOR/CONSULTANT ADDRESS II ‘ 0 git.N` It e 0 tive. Cri-YISTATEMe c1s./1C4 "'el/ CA 414S" 20 <br />LICENSE )(C-57 C-61 D-09 Other NUMBER 103 it 165 EXPIRATION DATE <br />BILLING PARTY: OWNER CONTRACTOR VSUBCONTRACTOR/CONSULTANT <br />tg2.4tCr_e ARCEL SUE LAND USSPPLICATION # <br />fv' 1-1R- PHONE Zairt .2-C4!)263 <br />A ..r?CF Jc APN <br />CP447 t)*117 ifr" Anclree f.6 <br />dt u <br />cnyisTATE/zip c q VS76 <br />PHONE <br />CrrY/STATE/Zus ROSE L); C 4 11566 I <br />Contact Name or Phone Number <br />WELL CONSTRUCTION <br />Drilling Method Mud Rotary Air Rotary )(Auger Cable Tool Push Point Other <br />Proposed Well Depth 50 it Excavation 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 L-C:' ft )( Neat Cement (94 lb bag/5-10 gal water) Sand Cement sack mixI7 gal water <br />Bentonite (20% solids) Other <br />Grout Placement Method Pumped Free Fall Other "rm. vat. . Retardant / Accelerator (name) <br />WELL/PUMP PERMIT <br />Codes <br />143PE7d <br />SC <br />Info <br />Received Check#4 <br />ash <br />Amount <br />Remitted <br />Permit/ <br />uest # Invoice # Well KV <br />150 <br />44 <br />1/75,0-- it 106,i-i I 073tel12, <br /> <br />poo <br />:.5 <br />EHI) 43-06 6 1112019 WELL rPUMP PERMIT