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WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAzeLTnu Avcwic <br />PERMIT <br />ADDRESS <br />.O <br />tOM DATE ISSUED <br />-r CITY1ZP <br />3f'kEETyv��(;/l!i[t`6' APN ®� I f 500Z <br />PARCEL 512E L -LAND USE APPLICATION ## <br />NAME lac/ -7 J Sp (+6J <br />PHONE_ <br />OWNERADDRESS /T�jJ CITY/STATE/ZIP_ �j <br />CONTRACTOR 9_id I \ 20.ST 1/�f A� PHONE 3 f-"2-•+ (�_ <br />CONTRACTOR ADDRESS ,70- CIN/STATE/ZIP 4442A& // w <br />SUBCONTRACTOR/CONSULTANT 45ao'r 7 <br />PHONE c� 7 T//., <br />1a <br />SU13CONTRACTORICONSULTANT ADDRESS CITY/STATEIZIP <br />LICENSE d91,-57 ❑ C-61 ❑ D-09 D Other NUMBER 3 7730 l- EXPIRATION DATE C L7 <br />BILLING PARTY: 0 OWNER -RXONTRACTOR ❑ SUBCONTRACTORICONSULTANT <br />­­ I - • =LL WAMVLING: u ueneral Mineral/Coliform Bacteria (4391) D Dibromochinrnnrnnnno fdzQ')% n A­nl /A�n0% <br />INTENDED USE Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring D Soil Sampling/Characterization <br />D Public Water System <br />If different from Owner: Water System Name Contact Name or Phone Number <br />TYPE OF WORK New WeII D Replacement Well ❑ Well Alteration/Mmiifir fine n rv— <br />D Monitoring Wells) # of wells ❑ Soil Boring(s) # of borings ❑Geotechnical <br />❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />A lew Pump ❑ Pump Replacement ❑ PUITID Reoair n kaicc %Aron f' a.... <br /># of borings <br />Drilling Method )WrMud !RR�'otary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other 19 <br />- <br />Proposed Well Depth 761� ft Excavation _/7- In diameter 0 Open Bottom AJ:Gravel Pack/Gravel Size in diameter <br />0 Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter j in Thickness/Gauge/ASTM Sched ZJD,'�,'O D Steel Plastic ❑ Stainless Steel ❑ Other <br />Grout Seal Depth f,7J It 0 Neat Cement (94 /b bag/5-10 gat water) 'Sand Cement %f% '3 sack mix/7 gal water <br />❑ Bentonite (20% solids) 0 Other <br />Grout Placement Method B<Umped ❑ Free Fall ❑ Other ❑ Retardant / Accelerator (name) <br />PEDESTAL Installed By >Obriller 0 Pump Contractor ❑ Other <br />❑ Concrete Pedestal ❑Dimensions: Width ft Length ft Thick in ❑ Christy Box 0 Stove Pipe <br />PUMP 19:eubmersibleo Turbine ❑ Other HP Pump Set ft Standing Water Level ft <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 />MINI�MI}M g8_HODU ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209)` 953-7697 <br />SIGNED-%GCiC-lyv/� TITLE OI�%�'L DATE la- <br />DE ARTMENT USE0 LY <br />Application Accepted By _ Date b LZ � t <br />Grout Inspection By C/•^ c.` q_ Date - <br />Pump Inspection By D <br />Soil Boring Inspection By <br />COMMENTS <br />ate <br />Date <br />Area 1 ` Employee ID# <br />❑ SPECIAL Well Permit <br />❑ WAIVER Received ��%% <br />Constructed Well Depth 1 6 r <br />I <br />� <br />. . <br />������y�]� yy: yl.�. <br />MIN i -l�W�VAUS `, • <br />EHD43-06 6/11/2019 WELL/PUMP PERMIT <br />