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WELL/PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVFNI— Sm^.., •,.,rn.,e...,� ,. NUR-KEFUNDABLE PERMIT 2 wWWs' OV.Or lehd EXPIRES 1 YEAR FROM DATE ISSUED Joe ADDRESS 3 ( y^ t C �j c ,� j 1 1 � I � (.ITYlZJP� CROSS STREET J Or I' 1 Ct Y) y- V% • APN �•' A PARCEL SIZE LAND USE APPLICATION # OWNER NAME �, /lam/ ��,��Lt (' ` /v T <t , r^. C� PHONE nn OWNER ADDRESS CONTRACTOR M CTTY/STATElLP C C'. -)C'.-) (_,� C 1-i i -1 � Y l� i� 1 ' 1 1 t'1 1 /PHONE �G' I J G' �1 - W 7 �C� CONTRACTOR ADDRESS i GI I.% 6x Y CTTY/STATEIZP CZ0 I I C �SUBCONTRACTOR/CONSULTANT PHONE SUBCONTRACTOR/CONSULTANT ADDRESS LICENSE 'XC -57 ❑ C-61 C D-09 ❑ Other BILLING PARTY: ❑ OWNER-XCONTrr CTTY/STATEIZIP NUMBER C S L EXPIRATONDATE 7-31 -,?J ❑ SUBCONTRACTOR/CONSULTANT DomesticlPrivate 0 - ---- ---•••-•••• r��rl a uwwmm ocoropropene (4392) L' Arsenic (4393) NTENDEo USE IrtigatioNAgdcultural ❑Industrial ❑ Water ouality Monitoring ❑Soil ❑ Public Water System Sampling /Characterization If different ham Owner: WaterSystem Name Conlad Name or Phone Number TYPE OF WORK '{New Well M RenI--t W.11 n loran — L, Monitoring Well(s) # of wells ❑ Soil Bodng(s) 8 of borings ❑ Geotechnical # ofbodngs ❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair DrIIILng Method t Mud Rotary 11 Air Rotary EJ Auger ❑ Cable Tool 11 Push Point C1 Other Proposed Well Depth O ft Excavation in diameter ❑ Open Bottom Gravel Pack/Gravel Size _' q n diameter F1 Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter -( -I-- in Thickness/Gauge/ASTM Sched C OLY L' Steel ,`9 Plastic D Stainless Steel :7 Other Grout Seal Depth lcr ft ❑ Neat Cement (94 1b bag/5-10 gal water) 'yf Sand Cement i> . =j sack mixrl gal water ❑ Bentonite (20% solids) E) Other Grout Placement Method ),(Pumped ❑ Free Fall 0 Other ❑ Retardant / Accelerator (name) PEDESTAL Installed By ZJS.Driller ❑ Pump Contractor ❑ Other Concrete Pedestal ❑Dimensions: Wdth S ft Length _� ft Thid in ❑Christy Box ❑Stove Pipe PUMP Submersible0 Turbine ❑ Other HPC Pump Set It Standing Water Level I ZI() ft I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WIT JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. QUIRED LICENSE IS WORKERS COMPENSATION LAWS. H SAN I ALSO CERTIFY THAT MY RE CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT IAM IN COMPLIANCE WITH ALL L O TlCE' I�?RQU''IRZFD Ct':�C C219NSa-EC T IO2`!G - PLE.I4F7 C •al... r fl9) . H3.-'637 SlGNED r."'_T"I�"'I's"1 I inil._C.tiew'� I 1- t S r Ci t' r'1 1 DATE - L' TITLE_ V - E Application Accepted By Grout Inspection By Pump Inspection By Soil Boring Inspection By COMMENTS__ RTMENT USE ONLY Date �- Date Date Date Area Employee ID#- r ❑ SPECIAL Well Permit F1 WAIVER Received 1 Constructed Well Depth renew faT °-I--T�qfo TCuh� ; Remitted Date Service Reauest" Invoice # Well ID# 4145 e11U2019 t WELL PUMP PERMIT ' 7� 1238 3