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of benage <br />Pump Repair <br />in diameter <br />sack mix/7 gal water <br />0 Soil Boring(s) *of booms 'AL Geotechnical <br />0 Out-Of-Service Well Renewal <br />0 Pump Replacement O <br />O Cross-Connection Repair <br />Raise Well Casing <br />Depth / ft Excavation <br />Conductor Casino in diameter <br />Well Casing <br />Grout Seal <br />Diameter _ in Thickness/Gauge/ASTM Sched C Steel <br />Depth 'It 0 Neat Cement (94 lb bab/5-10 gal wa/erl <br />Bentonite (20% solids) C Other <br />4! in diameter 0 Open Bottom 0 Gravel Pack/Gravel Size <br />/ Conductor Casing Depth ft <br />0 Plastic U Stainless Steel U Other <br />Sand Cement <br />Monitoring Well(s) # of wells <br />3 Out-Of-Service Well <br />0 Nov/Pump <br />IWELL CONSTRUCTION <br />1-3rilling Method Mud Rotary 0 Air Rotary )e, Auger <br />'Proposed Well ; <br />Cable Tool 0 Push Point 0 Other :SSRHOCIV 311S 202/ <br />Date 11/),c1 s <br />EPARTMENT U E ONLY IL <br />Date <br />Date <br />Date <br />re,1rre4- I <br />Area ‘//11 Employee ID# 114 <br />C SPECIAL Well Permit <br />WAIVER Received <br />Constructed Well Depth ft <br />Application Accepted By <br />Grout Inspection By <br />Pump Inspection By 4 <br />_NOW/ <br />Soil Boring Inspection By /V fgr i • <br />COMMENTS ai-diik <br />WELUPUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1858 EAST HAZELTON AVENUE - STOCKTON CA 95206-6232 (209) 468-3420 NON-REFUNDABLE PERMIT <br /> <br />APN <br />Adc- <br /> <br />CITY/STATE/ZIP <br />(C.1-/1) 6 <br />CONTRACTOR ADDRESS /1-100 PirCif Vet- ADA. b <br />JOB ADDRESS I S3 "1- <br />CROSS STREET <br />OWNER NAME KR..060e_ <br />OWNER ADDRESS /7 -75-0 <br />CONTRACTOR /-1 <br /><74 11Z AL/ re `1" CiTy/STATEOP ir i,(*A 5 r 2V <br /> <br />www.sjdov.orgiehd <br />C-AT /176/ItAt 13-0 _sr vr- <br />N3( v-oho j, crfet. PARCEL SIZE 6 - LAND USE APPLICATION* <br /> <br />EXPIRES 1 YEAR FROM DATE ISSUED <br />Ciry/Zip c.t.rwv 2-/ 5— <br />PHONE f - 2- /7- <br />c CZA-AA (1,47,) CA 3• <br />PHONE 2t) - Y I iS <br />SuBcoNTRAcToR/CoNsuLTANT ADDRESS 7 1Y c, gt31.4 Ai) <br />,LICENSE C-57 D C-81 0 D-09 3 Other NUMBER <br />PHONE qt 5/. ? <br />CITY/STATE/ZIP (.-k-17- 1."4-Cait.A.C.kirdt, CA .9' <br />/ EXPIRATION DATE zy.ri <br />SUBCONTRACTOR/CONSULTANT' 14)6'1 Ge-oretainekA <br />BILLING PARTY: V-OWNER 0 CONTRACTOR C SUECONTRACTOR/CONSULTANT <br />DOMESTIC WELL SAMPLING: 0 General Mineral/Colifarm Bacteria (4391) 0 Dibrornochloroprapane (4392) 0 Arsenic (4393) <br />INTENDED USE 0 Domestic/Private 0 Irrigation/Agricultural 0 Industrial C Water Quality Monitoring `4•I'Soil Sampling/Characterization <br />Public Water System <br />It different from Owner. Wafer Syntem Name Contact Name or Phone Numbf.1 <br />TYPE OF WORK 0 New Well 0 Replacement Well 3 Well Alteration/Modification 0 Other <br />iGrout Placement Method C Pumped T.] Free Fall 0 Other 0 Retardant / Accelerator (name) <br />;PEDESTAL I Installed By 0 Driller 0 Pump Contractor 0 Other Concrete Pedestal CDImenstons: Width ft Length i <br /> -- <br />SubmersibleU Turbine 0 Other _ Pump Set ft Standing Water Level ft 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 WORKERS COMPENSATION LAWS. <br />MINIMUM 4E1 HOUR <br />SIGNED <br />ItPUMP <br />ft Thick in 0 Christy Box 0 Stove Pipe <br />VANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 963-7697 <br />TITLE &It ovetA. DATE 3 I <br />4 <br />erA <br />PE <br />Codes <br />SC <br />Info <br />Received <br />B ., <br />Check#/ <br />Cash <br />Amount <br />Remitted Date Permit/ <br />Service Re uest # Invoice # Well ID# <br />i I'V / L ti2L_ -11P/09 4V1?-1 <br />`V41 (.1 //-- 1 yioe Li 1q12-1 <br />A00 414 i <br />4004- <br />n <br />EHD 43-06 6/11/2019 <br /> <br />&Pt, / 23 57 2-24 <br /> <br />WELL /PUMP PERMIT