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Monitoring Well (s) At of wells i Soil Boring(s) A nP raonlos 1 Geutechnical <br />Out-Or-Service well I Out-Of-Service Well Renewal , Cross-Connection Repair <br />'X New Pumn 7 Porno Renlariernent 7 Pumn Renoir 1 R.ligf, WRII nng11111 <br />WELL CONSTRUcTIN <br />h[1:1 /11, <br />Drilling Method - Mud Rotary - Air Rotary C Auger - Cable Tool - Push Point 7 Other <br />Proposed Well Depth ft <br /> <br />.. Conductor Casing in diameter / Conductor Casing Depth ft <br />Excavati on in diameter i Open Bottom Gravel Pack/Gravel Size in diameter <br />Well Casing Diameter in Thickness/Gauge,ASTM Sched II Steel :11 Plastic C Stainless Steel 1 Other <br />Grout Seal Depth ft - Neat Cement (94 lb beg/5-10 gal water) 1 Send Cement sack mixt? gal water <br />Bentonite (20% solids) i Other <br />Grout Placement Method Pumped I Free Fall Other I Retardant / Accelerator (name) <br />PEDESTAL Installed By _ _ Pump Contractor i Other <br />Concrete Pedestal Dimensions: Width II Langlh ft Thick in Christy Box Stove Pipe <br />rT, <br />JOA 1 202/ <br />te0N4/11V Coo 7.), <br />4/7_ <br />cs3Q_,Q <br />4pR 0 <br />Cia-k.t4 <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL. HEALTH DEPARTMENT I BEB EAST HA2ELT0N AVENUE - STOCKTON CA 05205 -6232 (209) 468-3420 <br />NON-REFUNDABLE PERMIT WWW.sjgov.oriliehd EXPIRES 1 YEAR FROM DATE ISSUED <br />Joa Ano CirelZiF allY lel Ilr:1 rtEss V/U? 66 XJr TREEP4472 9530 _ <br />CROSS STREET ...1-1N4-_661 C.-- APN ai2 ri 1,..9 0; ..-17 PARCEL SIZE q' 1-' 'LAND USE APPLICATION # <br />OWNER NAME qe:6E•Pli F ,4-4113ArRaA PHONE c/C) 'II/ 7/t& <br />OYYNER ADDRESS /I37 L. 4AP Sac) PM), <br />cimsTATEop CA/S-WO dALLEY 94(.53, <br />CONTRACTOR <br /> tA)ILEkse. <br />PHONE <br />CONTRACTOR ADDRESS CITV:S7 AT E1ZIP <br />SUBCONTRACTOR/CONSULTANT PHonE <br />SUBCONTRACTOR/CONSULTANT ADDRESS CITY/STATE/ZIP <br />LICENSE C C-57 l C-A 1 0-09 1 Other NUMBER EXPIRATION DATE <br />BILLING Parcry: OWNER I CONTRACTOR I SLINCONTRACTORiCONSULTANT <br />DOMESTIC WELL SAMPLING: = General Mineral/Collform Bacteria (4391): Dibromochloropropane (4392)0 Arsenic (4393) <br />ItintENoco USE Domeslic/Private I Irrigation/Agricultural Industrial Water Quality Monitoring Soil SamplinglCharactenzation <br />Public Water System <br />II different hem Owner: Water Lq,,.em Narne Contact Name Cr Plane Number <br />TYPE OF WORK New Werl Replacement Well I Well Atterancn/Modifimaticn L Other <br />PUMP Submersible: Turbine 7 Other I if- Pump Set ft. Standing Water Levei <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 />SIGNED <br />UM 48 HOlepUNCE 071 FO INSPECTIONS • PLEASE CALL (209) 953-71397 <br />TITLE DATE - <br />1 <br />tO' <br />iii <br />- <br />DEPARTMENT USE ONLY <br />Application Accepted By <br />z_z. <br />Dte -ii it3/4 <br />Grout Inspection By Date <br />Pump Inspection By(S:12,2nsaLekt4aptil Date S I i1_( L\ <br />Soil Boring Inspection By Date <br />COMMENTS r Je LJ v,J-1-10.-15-1 0 - 0 ; • . • _..%,.1%•&? <br />— <br />ft, <br />Area Employee IDS' <br />-.-. SPECIAL Well Permit <br />= WAIVER Received <br />Constructed Well Depth <br />PE <br />Codes <br />SC <br />Into <br />Recelved 14.71 <br />-risilb <br />Amount <br />Remitted <br />Date <br />i <br />Permit/ <br />Service R ue Invoice 0 Well ENO <br />93e3 psi —Tqc)7/- 4.)s2 FA, i',1 24 tAIMO I 71- <br />........-- <br />END 4346 6/11/2019 WEU. PUMP PERMIT