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Application Accepted By <br />Grout Inspection By <br />Pump Inspection By A • (-I. <br />ARTMENT USE ONLY <br />Date Li/di‘1/4 / <br /> Date <br />Date S 112-1 -2 -2 WAIVER Received <br />DEP <br />1 <br />cej <br />Area -1 Employee ID# • <br />SPECIAL Well Permit <br />oxl Env r'•A14, <br /> A44 <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 -6232 (209)468-3420 <br />NON-REFUNDABLE PERMIT WWW.S.• ov.or iehd EXPIRES 1 YEAR FROM DATE ISSUED <br />CROSS STREET lik,N) Y 1"3-7— APN .9(71-t; i C2 0 i 7 PARCEL SIZE2R- / C'e' LAND USE APPLICATION # N /it <br />JOB ADDRESS il 0 0 5. iL.'• . c-e, rz...c.... , cmgzi, 1 p<kL1 9 c) <br />OWNER NAME G r C‘ •A N' A `-q•-• 627 ,' Im i-A-L-1-.`C-4,1 Co--15---1 /4-1 PHONE 9 i (, - z5 5 - t 04 oc) <br />OWNER ADDRESS P.Q . ...-e "X i 6 z..S.---7- CITY/STATE/ZIP 5 ( US ctWletatir-C) , CA 151A / <br />CONTRACTOR GAR t;A'ACki-- PHONE 551 - C/1" - 7 Li- I <br />CONTRACTOR ADDRESS g 9 C-r c>/\ CITY/STATE/ZIP Re--9-2Z Q.1 CA 9 3 r? <br />PHONE SUBCONTRACTOR/CONSULTANT <br /> CrrriVrxrear SUBCONTRACTOR/CONSULTANT ADDRESS <br />VC-61 7 D-09 Other NUMBER i c15 I 5 0 EXPIRATION DATE LICENSE IVC-57 <br />El OWNER IhONTRACTOR SUBCONTRACTOR/CONSULTANT BILLING PARTY: <br />DOMESTIC WELL SAMPLING: D General MineraVColiform Bacte ia (4391): Dibromochloropropane (4392)1] Arsenic (4393) <br />INTENDED USE 7 Domestic./Private El Irrigation/Agricultural yflndusliial fl Water Quality Monitoring 7 Soil Sampling/Characterization <br />'2 Public Water System <br />Contact Name or Phone Number Water System Name If different from Owner <br />TYPE OF WORK I New Well i I Replacement Well , Well Alteration/Modification i I Other <br />3 Monitoring Well(s) # of wells F Soil Boring(s) ROT borings I-, Geotechnical # of banngs <br />_i Out-Of-Service Well t_ put-Of-Service Well Renewal U Cross-Connection Repair <br />3 New Pump _i Pump Replacement 'Eti Pump Repair 5 Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method :] Mud Rotary r As Rotary 1: Auger II Cable Tool Push Point r: Other <br />Proposed Well Depth ft Excavation In diameter Open Bottom El Gravel Pack/Gravel Size In diameter <br />- Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter in Thickness/Gauge/ASTM Schad C Steel C Plastic D Stainless Steel El Other <br />Grout Seal Depth ft Li Neat Cement (94 lb bag/5-1D gal water) C Sand Cement sack mix/7 gal water <br />Bentonite (20% solids) 11 Other <br />Grout Placement Method i i Pumped 7 Free Fall 7 Other 1 Retardant /Accelerator (name) <br />PEDESTAL Installed By El Driller E Pump Contractor = Other <br />Concrete Pedestal oDlmenslons: Width ft Length ft Thick In 0 Christy Box D Stove Pipe <br />7 Submersible /Turbine Li Other HP Pump Set (1C-" ft Standing Water Level 35,3 PUMP <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 UCENSE IS <br />CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE UCENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATION LAWS. <br />MINIMUM 4 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE,CALL (209) 953-7697 <br />SIGNED <br /> <br /> TITLE VsCA Vck' DATE Lel Z2 z -- <br />l Soil Boring Inspection BY Da <br />V\ V60-4( COMMENTS po t "I <br />e <br />I:ell!, <br />Constructed WelDepth t dl <br />PE <br />Codes <br />SC <br />Info <br />Received Checicfr/ <br />Cash <br />Amount <br />Remitted <br />Perrnit/ <br />Ryalue2t4t invoice A Well IDX <br />i:',11 c)•z. 0 <br />,,i1)39_. <br />Vi 6,0--- la -Y -7 24 <br />Fel <br />.!-2 <br />rfICR <br />VII 001-t I C-144 43 <br />EHD 43-06 6/11/2019 <br />(AV 22-H 7 1 231 <br /> WELL /PUMP PERMIT