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NON-REFUNDABLE PERMIT wwvv.sjgov.org/ehd <br />JOB ADDRESS :c...3.11-VC 6-/ C ,c((; <br /> <br />EXPIRES 1 YEAR FROM DATE ISSUED <br />CITY/ZIP <br /> <br />CROSS STREET(kIliv,r\r <br />\12901 i 3i)k--/ , <br />- NCI APN (7c1a7,,,(11174 '.),I, ,t, <br />6 ity9, <br />EL SIZE (":" f-::- LAND USE APPLICATION # A <br />OWNER NAME L - _c, \,) i t y DO rj el VI a -ig (2- 7 /1 L_ . PHONE <br />OWNER ADDRESS pu EZ4 7Je, CITY/STATE/ZIP oakdolie <br />PHONE (ar6 <br />CITY/STATE/ZIP 1.-ork 1.521-1L) <br />PHONE <br />SUBCONTRACTOR/CONSULTANT ADDRESS C‘C4 N PA '`‘ <br /> <br />CITY/STATE/ZIP -; 01 °I 2Eib 1 <br />I Tt 'IN t • V_Li <br />CONTRACTOR ADDRESS 0 ), VIC^-f <br />SUBCONTRACTOR/CONSULTANT IA' Ci d r (5?0 Tric <br />CONTRACTOR <br />LICENSE V( C-57 ' C-61 in D-09 '1 Other NUMBER PO 1151 EXPIRATION DATE - 30 -a 3 <br />BILLING PARTY: 0 OWNER ‘/CONTRACTOR ' SUBCONTRACTOR/CONSULTANT <br />DOMESTIC WELL SAMPLING: El General Mineral/Coliform Bacteria (4391) iDibromochloropropane (4392) L Arsenic (4393) <br />INTENDED USE Domestic/Private I Irrigation/Agricultural Industrial Water Quality Monitoring : Soil Sampling/Characterization <br />Public Water System <br />If different from Owner: Water System Name Contact Name or Phone Number <br />Li New Well Replacement Well E Well Alteration/Modification I Other <br />Li Monitoring Well(s) <br /># of wells 1:1 Soil Boring(s) */ of borings Geotechnical # of borings <br />0 Out-Of-Service Well <br />[7 Out-Of-Service Well Renewal 0 Cross-Connection Repair <br />El New Pump [7 Pump Replacement I] Pump Repair E Raise Well Casing <br />TYPE OF WORK <br />PUMP Submersible Turbine I Other HP Pump Set ft Standing Water Level ft <br />ft Thick in Li Christy Box I Stove Pipe <br />PEDESTAL Installed By Driller I Pump Contractor - Other <br />Concrete Pedestal iDlmensions: Width ft Length <br />WELL CcAsmucTioN <br />Drilling Method ri Mud Rotary C Air Rotary I Auger Cable Tool Push Point Other <br />Proposed Well Well Depth 5C, ILL ft Excavation in diameter Open Bottom 0 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 I Plastic 1 Stainless Steel Other <br />Grout Seal Depth j , ft Neat Cement (94 lb bag/5-10 gal water) Sand Cement <br />Bentonite (20% solids) Other <br />Grout Placement Method Pumped Free Fall A, Other Tie-PA \ e 11 Retardant/Accelerator (name) <br />sack mix/7 gal water <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 />1 <br />rc:iim q m 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />SIGNED /11/k/— 1r, /1„ <br />TITLE 17- Urotoc) ,s-r DATE °I • G- \ <br />t\C <br />7. <br />ce <br />1 614N <br />Date i WAIVER Received <br />Date ,DC( 2-024 Constructed Well Depth <br />n a re d )j <br />ft <br />102\5 0 63. <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAzELToN AVENUE - SioctcroN CA 95205 -6232 (209)468-3420 :SMICICIV 311S Application Accepted By <br />Grout Inspection By Date <br />Pump Inspection By <br />DEPARTMENT USE ONLY <br />Date qpiz_,7/ <br />Soil Boring Inspection By <br />COMMENTS t <br />Area 1 EmD,ovee ,D# <br />SPECIAL Well Permit <br />PE <br />Codes <br />SC <br />Info —Cash <br />Received c Check) Amount <br />Remitted Date Permit/ <br />Service Request # Invoice # Well ID# <br />14-3 -2- ).6"-C zikl- 2, 3 2 _j6. _ i s 4_ ( ) /,' ' i vv Pc) 0 '05E5- <br />EHD 43-06 6/11/2019 WELL /PUMP PERMIT