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ERMIT PERMIT <br />� XPIIED WELL/PUMP PERMIT CV�/�p rCja'�y <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 18$8 EAST HAZELTON AVENUE - STOQIjyC7 P11Z U D232 (209) 468-3420 <br />IMV1v-Ktl-UNDABLE rEFZM1T WWW.sjgoy.Org/ena (.wtAF'IKtb 'I YEAR FROM DATE ISSUED <br />JOB ADDRESS SNbD �� _ CITY/Z�IPP MA�v�.'� t ^ f lY 37 <br />CROSS STREET �'Kr1rd.1^}-- _ Y APN ZZ—650-6Z, PARCEL SIZE ' ' AND USE APPLICATION # <br />OWNER NAME V r t A l I\/ ?A4yill-s41 PHONE�I�dZ��Z�� <br />OWNER ADDRESS 11 t� W A�I1�Q16 A IAA- �+" t CITY/STATE/ZIP dK.ype jV � �� [ �3 <br />CONTRACTOR �t�lls tll� vie PPHONE S2Z- l/1�2,0 <br />L <br />CONTRACTOR ADDRESS ` ,e I�r/1 J U. CITY/STATE/ZIP I//S'� <br />SUBCONTRACTOR/CONSULTANT <br />SUBCONTRACTOR/CONSULTANT ADDRESS <br />LICENSE 'di C-57 ❑ C-61 U D-09 t i Other, <br />PHONE <br />CITY/STATE/ZIP <br />NUMBER EXPIRATION DATE <br />BILLING PARTY: I i OWNER 'CONTRACTOR SUBCONTRACTOR/CONSULTANT <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/Characterization <br />❑ Public Water System <br />If different from Owner: Water Svstem N <br />TYPE OF WORK X New Well ❑ Replacement Well ❑ Well Al it <br />I] Monitoring Well(s) # of wells 1 Soil Bor <br />❑ Out -Of -Service Well ❑ Out -Of -Service <br />❑ New Pump ❑ Pump Replacement ❑ Pump Repair <br />Contact Name or Phone Number <br />❑ Other <br /># of borings ri Geotechnical <br />1 ❑ Cross -Connection Repair <br />❑ Raise Well Casino <br /># of borings <br />Drilling Method )(Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other <br />Proposed Well Depth -104:1 ft Excavation /2- in diameter ❑ Open Bottom Iravel Pack/Gravel Siz _ in diameter <br />❑ Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter, i Thickness/Gauge/ASTM SchedZ ,� ❑ Steel )('Iastic ❑ 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 />Groupcement Methodumped ❑Free Fall ❑Other ❑Retardant /Accelerator (name) <br />WW—EW Installed By ❑ Driller ❑ Pump Contractor ❑ Other <br />❑ Concrete Pedestal ❑Dimensions: Width ft Length AI -...ft Thick in ❑ Christy Box ❑ Stove Pipe <br />Mi � ❑ SubmersibleTurbine Cl Other HP PumpSe[ ft Standing Water Level <br />Q.H Y CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND 49&tfj WILL BE DONE IN ACCORDANCE WITH S <br />JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. MS10 CERTIFY THAT MY REQUIRED LICENSE <br />CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH AIL, <br />WORKERS COMPENSATION LAWS. �J <br />D PA TMENT USE ONLY <br />Application Accepted By , ate Area Employee IDti <br />Grout Inspection By Date PECIAL Well Permit <br />Pump Inspection By <br />Soil Boring Inspection By <br />COMMENTS <br />Date <br />Date <br />WAIVER Received <br />Constructed Well Depth <br />in <br />T <br />D <br />0 <br />v <br />X <br />m <br />N <br />EHD 43 -GG 6/1112019 WELL /PUPo1P PERMIT <br />�J n,'011 <br />/1Ii10'__ <br />*'-wT <br />Sr <br />.�I/�%/ <br />�Fys✓,�%�6�1�i�r1G����t1111 <br />6111 FMU A0 <br />,� <br />©� ) ( M= <br />_ <br />EHD 43 -GG 6/1112019 WELL /PUPo1P PERMIT <br />