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Water System Name Contact Name or Phone Number <br />Well Afteration/Modification <br />Soil Boring(s) <br />Out-Of-Service Well Renewal <br />Pump Repair <br />Other <br />of borrigs <br />Geotechnical <br />Cross-Connection Repair <br />Raise Well Casing <br />a of bctings <br />DEPARTMENT USE ONLY <br /> <br /> Data CO tO d <br />Pump Inspection By / <br />Grout Inspection BY <br /> Dpaattee le 7 ,r <br />Soil Boring laseection By Date COMMENTS 1...)"0/ i,'Yi17—T—:—T--T-Irr / i 1 gi: e_s CIF v•i <br />Application Accepted By <br />1 <br />Date Service Request # <br />122" ttiP0U 43121 <br />Permit/ <br />WELL/PUMP PERMIT <br />SAN JOAQUIN CoUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - S-rocicroN CA 95205 -6232 (209) 468-3420 <br />NON-REFUNDABLE PERMIT www.sigov.orgiehd CArlittb 1 TEAR FROM DATE ISSUED <br />t ( Rout)9 JOB ADDRESS <br />. <br />CirfrZIP r \- A vl t Ca% S 2-!ti <br />CROSS STREET E SC‘il 3n — ApN 18 7 3 000ci PARCEL SUE 14 LAND USE APPLICATION # <br />PHONE <br />orrisTATEizie f -ox „Tv\ `k 0 (A t C-4\ <br />PHONE -7-0 - 6-13 <br />CITY/STATE/ZIP Mo 4- oi CA 3 6 <br />PHONE <br />CITY/STATE2IP <br />.0-09 Other NUMBER 411 ((do 0 EXPIRATION DATE \ 31 - <br />_21.1TRi_2t.L02......)q SUBCONTRACTOR/CONSULTANT <br />DOMESTIC WELL SAMPUNG: General Mineral/Co//form Bacteria (4391) Dibromochloropropane (4392) Arsenic (4393) <br />INTENDED USE rtrir—nestic/Pria 11> Irrigation/Agricultural Industrial Water Quality Monitoring Soil Sampling/Characterization Public Water System <br />If different from Owner <br />TYPE OF WORK New Well Replacement Well <br />Monitoring Well(s) # of wells <br />Sy) .t-Crf-C rvice Well <br />c"-New XPump Replacement <br />WELL. CONSTRUCTION <br />Drilling Method Mud Rotary Air Rotary Auger Cable Tool Push Point Other Proposed Well Depth ft Excavation in diameter Open Bottom Gravel Pack/Gravel Size in diameter Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter in Thickness/Gauge/ASTM Sched Steel Plastic Stainless Steel Other Grout Seal Depth ft Neat Cement (94 lb bag/5-10 gal water) Sand Cement Bentonite (20% solids) Other <br />Grout Placement Method Pumped Free Fall Other <br />PEDESTAL Installed By Driller Pump Contractor Other Concrete Pedestal Dimensions: Width ft Length ft Thick in Christy Box Stove Pipe <br />HP '7_ Pump Set 'T.- CIO ft Standing Water Level I t-14 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 />WORKERS COMPENSATION LAWS CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE UCENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />.., <br />-MINIM - 48 HO . . DVA - NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 SGNED i <br />— ..--- ..,,. „.....„ <br />TITLE DATE <br />I <br />-I. <br />it <br /> <br />i ..mplitimmuyi <br />PAYMENT <br />RECEIVED <br />SEP 14 2022 <br />OWNER NAME \LA r \\ <br />OWNER ADDRESS ZAD (1-1- / 0‘. <br />CONTRACTOR Ctr-S A rt-t AA es If, c <br />CONTRACTOR ADDRESS s---00\ uk...R ). pat <br />SUBCONTRACTOR/CONSULTANT <br />SUBCONTRAcToR/CoNSULTANT ADDRESS <br />LICENSE C-57 <br />BILLING PARTY: OWNER <br />sack mixI7 gal water <br />Retardant / Accelerator (name) <br />I PUMP SubmersilA) Turbine Other <br /> :SSMICIOV 311S SAN JOAQUIN COUNTY_ <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />Area ii/Ci CI Employee ID# <br />/vie <br />SPECIAL Well Permit <br />WAIVER Received <br />Constructed Well Depth ft <br />PI in efe‘i per peintif - <br />PE SC <br />Codes Info <br />.4431f/_ 5.0 <br />Recei <br />Check* <br />, :• irifILVIVA <br />Amount <br />Remitted <br />4. 7 -7 <br />END 43.05 6/11/2019 <br />puk 1-4/- <br />Invoice # <br />Well ID# <br />/PUMP PERMIT