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„.; tau._ <br />PHONE o9i - teca <br />COY/STATE/ZIP SUBCONTRACTOR/CONSULTANT ADDRESS <br />EXPIRATION DATE NUMBER <br />JOB ADDRESS S950 E CI.XSOPSF--19C-tE <br />CROSS STREET APN /7- -ego —518 PARCEL SIZE i13 i LAND USE APPLICATION # <br />CONTRACTOR ADDRESS <br />SUBCONTRACTOR/CONSULTANT <br />Ot151,0r_g- CITY /STATE/2IP <br />PHONE <br />crrezie (4).e.1VA,Pe, <br />OWNER NAME <br />OWNER ADDRESS <br />CONTRACTOR <br />CITY/STATE/ZIP <br />`9-ktku9( — lAtFcl-ok' <br />HONE cZeR —3(04-C;— PPS'? (Cr <br />LICENSE C-57 <br />BILLING PARTY: <br />C-61 0-09 Other <br />TOWNER _ CONTRACTOR _ SUBCONTRACTOR/CONSULTANT <br />51t-kkit.E- <br />ft Pump Set ft Standing Water Level HP PUMP Submersible Turbine Other <br />WELL CONSTRUCTION <br />Drilling Method Mud Rotary Air Rotary Auger Cable Tool Push Point Other <br />in diameter / Conductor Casing Depth ft <br />Grout Placement Method Pumped Free Fall Retardant / Accelerator (name) Other <br />ft Thick <br />PEDESTAL Other <br />ft Length in _ Christy Box _ Stove Pipe <br />Installed By Driller Pump Contractor <br />Concrete Pedestal _ Dimensions: Width <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched Steel Plastic Stainless Steel Other <br />Grout Seal Depth ft Neat Cement (94 lb bag/5-10 gal water) Sand Cement sack mix/7 gal water <br />Bentonite (20% solids) Other <br />Proposed Well Depth ft <br /> <br />Conductor Casing <br />Excavation in diameter Open Bottom Gravel Pack/Gravel Size In diameter <br />VIR'eUINc° <br />7-4°NrY 7.1696"pm6A/ AR I. NENT <br />WELLJPUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STocicrow CA 95205 -6232 (209)468-3420 <br />NON-REFUNDABLE PERMIT www.sjgov.orgiehd EXPIRES 1 YEAR FROM DATE ISSUED <br />DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic (4393) <br />INTENDED USE Domestic/Private _ Irrigation/Agricultural _ industrial Water Quality Monitoring _ Soil Sampling/Ch#racterization <br />Public Water System Robi.,,+ kut w ,neil 0P4er Sys-toy' f>e,ilifx , <br />If different from Owner. Water System Name Contact Name or Phone Number <br />TYPE OF WORK <br /> <br />New Well Replacement Well Well Alteration/Modification Other <br />Monitoring Well(s) # of wells Soil Boring(s) 0 of borings . Geotechnical # of bonngs <br />Out-Of-Service Well <br /> <br />Xrut-Of-Service Well Re I Cross-Connection Repair <br />New Pump Pump Replacement <br /> <br />pump Repair fg Raise Well Casing <br /> <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 />MINIMUM 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953 <br />SIGNED Trri.E i.) ire4or DATE <br />i <br />707, <br />13 /Z <br />l III_ __Lilir111111111111, ,..FIRIMII <br />railiglillridllladd9aill1111111111 111111111111111111114 0122 P1:3111111E1111111 <br />It!! <br />11111111 ill 111111 r. <br />/DEPARTMENT dSE ONLY <br /> <br />Application Accepted By ea 'if Employee IDS F <br /> <br />Grout Inspection By <br /> Date / Ar <br /> <br />Dale SPECIAL Well Permit <br />Pump Inspecdon By ''t•cets...' ( 470,, 4, Dale iglap.z.f WAIVER Received <br />" er- 1 Jo SpOci z,ri mai rietiy9 -27M-1-vna..,Niwilly <br /> <br />Soil Bonng lAspecton By Constructed Well Depth <br />COMMENTS Ktfiev.k: <br />01- otele/ weli‘ P cum. :t "nz": re145: <br />rr6,4 <br />PE <br />Codes <br />SC <br />Info <br />Received Check/AI <br />Cash, <br />Amount <br />RemItted <br />Permit/ <br />ice Ragtag* Invoke 0 Well 100 <br />43(-‘1 ill' ,649 .6ePetir fig); <br />ft./ <br />ti k VisereiVqvditill <br />ENO 3-0.1 V14oll WELL IRsiP PERIMT <br />5)1.-14" /2,s-s24/57.2_