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1113 <br />WELLIPUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEAL-riq DEPARTMENT 1868 EAST HAZELTON AVENUE - 3TOCK-TON CA 95205 -.6232 (209) 468-3420 <br />NON-REFUNDABLE PERMIT C /E�hd EXPIRES 1 YEAR FROM DATE ISSUED <br />JoL,L Aix)r-zESS CITY/ZIP <br />CROSS STREETC?.Vj <br />APN _AV-001ARCEL SIZE,2-6#9LAND USE APPLICATION <br />617 <br />OWNER NAME <br />PHONE -3 <br />OWNER ADDP'FSS CITY/STATEI7_IP6e't L/. <br />CONTRACTOR PHONE 31V-' <br />CONTRACTOR ADDRESS Rb- 4,o z,—. -L CITY/STATE/ZIP <br />SuEICONTRACTOR/CONSULTANT <br />SUBCONTRACTOR/CONSULTANT ADDRESS <br />LICENSE 1! C-57 i'1 C-611 11 D-09 <br />BILLING PARTY: OWNER <br />DODALSTIC WELL SAMPLING:' <br />INTENDED USE I I Domeslic/Private <br />PFIONI- <br />CITY/STATE/ZIP <br />Numr3ER3-777Zr EXPIRATION DATE 1Z / <br />CONTRACTOR SLIBCON1 RACTOR/CONSULTANT <br />General Mineral/Coliform Bacteria (4391), Dibromochloropropane (4392) Arsenic (4393) <br />n/Agricultirial 1-1 IndLIStrial ..1 Water Quality Monitoring 11 Soil Sampling/Characterization <br />I I Public Water <br />Ifdiffnjont frnm Owner: Water System Norno <br />TYPE OI:WORK ( New well I Replocernent Woll I I Well Alteration/Modification <br />II Other <br />Conrad Natile or Phone Number <br />k I <br />Monitoring Well(s)_-- of wells 1-1 Soil Boring(s) __ A of holings F -i Geotechnical <br />Or it -Of -Service Well 0 Out -Of -Service Well Renewal L) Cross -Connection Repair <br />)-kNew Pump 11 Ptimp Replacement u Pump Repair ii Raise Well Casinq <br />11 of borings <br />Drilling Method YkMLId ROt,11Y it Air Rotary 0 Auger 11 Cable Tool ii Push Point I1 Other L:16141 <br />Proposed Wolf I)eptll _ISO�M ft Excavation in diameter U Open Bottom I i Gt,-iv(-,l Flack/Gravel Size in d r <br />ri C011CILIC101'CaGingin diameter- / Conductor Casing Depth It <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched -249 D Steel PkPlastic 0 Stainless Steel :-) Other <br />Grout. Seat Depth ft 11 Neat Cement (94 /b beg /a -�) — <br />--V g/5-10 gal water) ASand Cement sack mix/7 gal water <br />Bentonite (200/t, solids) 'd Other <br />Grout Placement Method Ft Pumped 11 Free Fall i-1 Other Ll Retardant / Accelerator (name) <br />PEDESTAL Installed By Xz)rillcr 1-1 Pump Contractor FI Other <br />I I Concrete Pedestal I iDirnonslons: Width _U __. it Length fl: Thick in Li Christy Box 1] Stove Pipe <br />Pump -- 'NSub i. iersible ui Tt u -bine i) Other 1-1p ';mb P"Inp Set— ft Standing Water Level R <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL LIE 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 HOU ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />SIGNED -TITLE_Z�� <br />DAIL. —t)- <br />P - IRTMENT �SE ONLY <br />\I,plicatian!\ccepteCl fig Date Awa Employee I D# <br />(;rout Inspection B Dat(-.- SPECIAL Well Permit <br />Pump <br />Inspection By Date <br />Soil Boring Inspoclion By <br />[Date, <br />(.',(.1MMEi\JTS' Keo'k &'!R6-5 <br />fPbil�$R <br />WAIVER Received <br />Constructed Well Depth <br />21 W <br />Pi: Sc <br />';-ldes 1 0 <br />--Py <br />Cash_Remitted <br />L TQ"5-- <br />Amount <br />- <br />Permit/ <br />Date Invoice # Well ID# <br />Service Request # <br />-7 0 4 <br />Ill) 1,, to (Y 1 1/2019 WELL /PUMP PERMIT <br />