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Stockion j cIS 20'-i <br />OWNER NAME <br />CROSS STREET VA*Ci. C.Aou.d Fivf. A P N j a 930 PARCEL SIZE LAND USE APPLICATION # <br />gcorN CAus _ (kR(1)4MN DA 23,4 W.- PHONE NM <br />rri 1,„ r ....,,„A ,,,,g. ir.k-t <br /> <br />OWNER ADDRF 3 q Do Detivt p; Ne CITY/STATE/ZIP 1/41'AP/tr., 0 i...0 • WO • 7,r — • "' ,I". <br />mi ck,ue fariAn c, eo To6titne PHONE (1I4) 633 - 502. <br />CONTRACTOR ADDRESS cl 54 K1 • Ltarion 1, <br />6e)$L 1**,0140 12.:/ itict/STLITsE/ZIIP LUE6JIRA <br />NUMBER 5710N DAITECiljaa42,0231 S6C" <br />LI CONTRACTOR 0 SUBCONTRACTOR/CONSULTANT <br />JOB ADDRESS 3 N S <br />CrrylZip <br />CONTRACTOR <br />SUBCONTRACTOR/CONSULTANT (Ake — 14 uh1 licoutaies <br />Orarot / CB I q 2-`gol CITY/STATE/Zit, <br />PHONE 01(0)&127 14 <br />SUBCONTRACTOR/CONSULTANT ADDRESS <br />LICENSE ki(C-57 0 C-61 0 D-09 0 Other <br />BILLING PARTY: DOWNER <br />TYPE OF WORK 0 New Well 0 Replacement Well 0 Well Alteration/Modification 0 Other <br />0 Monitoring Well(s) # of wells 0 Soil Boring(s) Cal borings ViGeotechnical ?) 4 °f balings <br />0 Out-Of-Service Well 0 Out-Of-Service Well Renewal 0 Cross-Connection Repair <br />0 New Pump 0 Pump Replacement 0 Pump Repair 0 Raise Well Casino <br />PUMP Pump Set ft Standing Water Level 0 Submersible 0 Turbine 0 Other HP ft <br />ft Thick <br />PEDESTAL <br />in 0 Christy Box 0 Stove Pipe <br />Installed By 0 Driller o Pump Contractor 0 Other <br />Li Concrete Pedestal ODimensions: Width ft Length <br />WELL CONSTRUCTION <br />0 Mud Rotary 0 Air Rotary 0 Auger 0 Cable Tool ihush Point 0 Other <br />Depth c13 ft Excavation in diameter 0 Open Bottom 0 Gravel Pack/Gravel Size <br />0 Conductor rasing in diameter / Conductor Casing Depth ft <br />Diameter . .. in Thickness/Gauge/ASTM Sched 0 Steel 0 Plastic 0 Stainless Steel <br />Depth SO ft ivileat Cement (94/b bag/5-10 gal water) 0 Sand Cement <br />0 Bentonite (20% solids) 0 Other <br />Grout Placement Method 0 Pumped /Free Fall Other -14Mitie 11J310 Retardant / Accelerator (name) <br />0 Other <br />sack mix T7 gal water <br />in diameter <br />Drilling Method <br />Proposed Well <br />Well Casing <br />Grout Seal <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 />MINIM M.48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />SIGNED TITLE I ,11. a . • • DATE IA/ 1)0 24 <br /> !WENT <br />RECEIVED <br />ENVI <br />NEALTI <br />/1 <br />SAN <br />PAY <br /> 21 2021 <br />QUIN COUNTY <br />CNMENTAL <br />DE-PRIRTMENT <br />WELL/PUMP PERMIT • <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - S rocKToN CA 95205 -6232 (209) 468-3420 <br />NON-REFUNDABLE PERMIT www.sjgov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br />DomEsTic WELL SAMPLING: 0 General Mineral/Coliform Bacteria (4391) 0 Dibromochloropropane (4392) 0 Arsenic (4393) <br />0 Domestic/Private 0 Irrigation/Agricultural 0 Industrial 0 Water Quality Monitoring Ail Sampling/Characterization <br />0 Public Water System <br />It different from Owner: <br />Area R/Sk'e: 44jilEmployee ID# <br />0 SPECIAL Well Permit <br />0 WAIVER Received <br />2-1 Constructgd Well Depth ift ?-0 ('e-'t.r 5 rDond vslate.r- <br />PE <br />Codes <br />SC <br />Info <br />Received <br />By <br />Check#/ <br />Cash <br />Amount <br />Remitted Date Permit/ <br />S : rvice Request # Invoice # Well ID# <br />tri ra 107 522114 47 Cb 10/21/21' ,, PI i , iff , fr <br />VJ i'd0 142&41 <br />INTENDED USE <br />Water System Name Contact Name or Phone Number <br />Soil Boring Ins ection <br />COMMENTS -ry e le, S <br />DEPARTMENT U E NLY <br /> <br />Application Accepted By 72 Date 0 <br /> <br />Grout Inspection By Date <br /> <br />Pump Inspection By Date <br />ate I <br />cleepee t' 4 <br />EHD 43-00 6/11/2019 WELL /PUMP PERMIT