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111111 <br />E ONL Y <br />Area Employee ID# :SS3210:1V 311S PA leivieN7-RECEIVED <br />MAR 12 2021 <br />SAN JOAQU/N <br />COUNTY ENVIRON MENTAL HEALTH DEPARTMENT <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE STOCKTON CA 95205 -6232 (209)468-3420 <br />APN <br />hr fo() Vaadet2- <br />OWNER ADDRESS) b CCfr-a:fri fed <br />e p s <br />1-704 -7 —mu gd <br />CITY/ZIP i <br />--.7-EXPIRES 1 YEA nCloATE ISSUED <br />k61 C a <br />- 1,2.cf PARCEA SIZE LAND USE APPLICATION # <br />PHONE 5(0 14 --r1Z (9() OdS 00 I , <br /> <br />)' CEA CS 5 3 Ot <br />JqC),,,10 <br /> <br />Mud() <br />c15-3co CITY/STATE/ZIP <br />pHoNivi <br />Q43112Z. NumBER,2-1 (.0 EXPIRATION DATE <br />CROSS STREET <br />OWNER NAME <br />CONTRACTOR <br />NON-REFUNDABLE PERMIT Www.sjgov.org/ehd <br />JOB ADDRESS <br /> <br />(17(-)0 br-4 ((t1P—fh <br />CITY/STATE/Z1 <br />CONTRACTOR ADDRESS <br />SUBCONTRACTOR/CONSULTANTIV <br />SUBCONTRACTOR/CONSULTANT ADDRESS NO CITY/STATE/ZIP 17f / <br />LICENSE _ C-57 _ D-09 U Other 0 <br />B1LUNG PARTY: - OWNER 'CONTRACTOR l SUBCONTRACTOR/CONSULTANT <br />INTE <br />DomEsTic WELL SAMPLING: 0 Genx1 Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic (4393) <br />ED USE _ Domestic/Privat ' Irrigation/Agricultural _ Industrial _ Water Quality Monitoring _ Soil Sampling/Characterization <br />(10 _ Public Water System <br />If different from Owner Water System Name <br /> <br />Contact Name or Phone Number <br />TYPE OF WORK New Well U Replacement Well <br />Monitoring Well(s) # of wells <br />_ Out-Of-ServicOyell <br />New Pump Ai, Pump Replacement <br />U Well Alteration/Modification J Other <br />#01 borings *of borings I 1 Soil Boring(s)Geotechnical <br />U Out-Of-Service Well Renewal Li Cross-Connection Repair <br />0 Pump Repair E Raise Well Casi <br />WELL CONSTRUCTION <br />Drilling Method _ Mud Rotary u Air Rotary u Auger _ Cable Tool L Push Point _ Other <br />Proposed Well Depth ft Excavation in diameter J Open Bottom L Gravel Pack/Gravel Size in diameter <br />_ Conductor Casing in diameter Conductor Casing Depth ft <br />I Well Casing Diameter in Thickness/Gauge/ASTM SChed J Steel Li Plastic _ Stainless Steel u Other <br />Grout Seal Depth ft n Neat Cement (94 lb bag/5-10 gal water) n Sand Cement sack mix17 gal water <br />= Bentonite (20% solids) Other <br />Grout Placement Method - Pumped rl Free Fall 11 Other 1-1 Retardant / Accelerator (name) <br />PEDESTAL Installed By - Driller 0 Pump Contractor 0 Other <br />_ Concrete Pedestal UDimensions: Width ft Length <br />( i‘ / <br />I PUMP X Submersible - Turbine n Other HP J Pump Set ft Standing Water Lev4 U ft <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPUCATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE INITH SAN <br />JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br />CURRENT AND AC11VE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATION LAWS. <br />SIGNED <br />mom mm simm mmimmom immummum Es um ummom • ;Alminnommumm m mmummommom <br />m• 111111101=311111 <br />II MENUMNIMMEMEM <br />IIMM <br />i SIBU <br />moimmormimmom <br />--- - aim m m• mom inumm• mil mmarammumm <br />blow= imminim miligimmammummumm IIMENNIFINUMMENNIIMMEMI <br />1 1 1 1 1 <br />D P A TMENT U <br />Application Accepted By Date 3 <br />Grout Inspection By <br />Pump Inspection By <br />Soil Boring Inspection 13/ Da <br />COMMENTS '?Orile <br />ft Thick <br /> <br />in _ Christy Box U Stove Pipe <br />-4211r <br />MIIMEMEMIM MUM milummummom <br />MEMO= <br />MEMINIEMME IIM MUMMUMMIIMEEM- or .immammum <br />immemm <br />trA <br />imm <br />IU mifiumaiu g Immo gum • <br />pram <br />1111:111111. a MIME MI Illm <br />MINI MU 8 0' ADVANCE NOTICE REQUIRED FOR P,I,SPECTIONS -PLEASE CALL (209) 954-7697, <br />TITLE DATE 07 f ,12,1 <br />• i MENUMMUME <br />Thu 11111111 1 <br />- r irri 1 1 I I I I I I <br />Date 0 SPECIAL Well Permit <br />Date 5 I 19 ) 1 0 WAIVER Received <br />Constructed Well Depth ft <br />PE <br />Codes <br />SC <br />Info <br />Received <br />lion <br />ICtle_c h# <br />as i <br />Amount <br />Remitted Date Permit/ <br />Service Request # Invoice # Well ID# <br />Lai ofo 6,N--- 313--ot -31- .312-z 14RA-iv <br />EHD 43-06 6/11/2019 WELL /PUMP PERMIT