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• <br />` VVEELL61PWVgr-1 P+aRN <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTI-I DEPT '1868 'East Hazelton Avenue - STOCKTON CA 95205-6232 - (209) 468-342Y <br />NUN-KEFUNDABLE PERMIT <br />ADDRESS <br />CROSS STREET LA_) I I <br />OWNER NAME <br />OWNERADDRESS <br />CONTRACTOR <br />CONTRACTOR ADDRESS <br />SUBCONTRACTOR <br />SUBCONTRACTOR ADDRESS <br />GA�/L�L (ZU9) 9b3 -Y69-17 FOR INSPECTION'S EXPIRES 1 YEAR FROM DATE ISSUED <br />Pd. _ <br />_APN V PARCELSIZE LAND JSE APPLICATION# <br />1^ PHONE / q— ja �.�'/J�� j <br />7�Y I� JCITY/STATGZIP�L./D�`—F �5J(-/`��n <br />rSPHONE <br />CIT`(/STATE/ZIP CA Q5�q <br />PHONE <br />CITY/STATE/ZIP <br />LICENSE X r-57 ❑ C-61 ❑ D-09 ❑ Other <br />NUMBER <br />EXPIRATION <br />INTENDED USE Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization <br />❑ Public Water System <br />If different from Owner: Water System Name L;ontaGt Name or Hhone Number <br />TYPE Of- WORK ❑ New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other <br />❑ Monitoring Well(s) # of wells ❑ Soil Boring(s) # of borings ❑ Geotechnical # of borings <br />❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />❑ New Pump k Pump Replacement ❑ Pump Repair ❑ Raise Well Casinq <br />WELL CONSTRUCTION <br />Drilling Method ❑ Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other <br />Proposed Well Depth ft Excavation in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel Size in diameter <br />❑ Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Sched ❑ Steel ❑ Plastic ❑ 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 />Grout Placement Method ❑ Pumped D Free Fall ❑ Other ❑ Retardant / Accelerator (name) <br />PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other <br />❑ Concrete Pedestal Dimensions: Width ft Leng+h ft Thick in ❑ Christy Box ❑ Stove Pipe <br />PUMP Submersible D Turbine ❑Other HP_/7j_ Pump Set ft `Standing Water Level ^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 />I <br />m <br />D <br />A <br />m <br />cn <br />D PARTMENT USE ONLY <br />Application Accepted By Date ` Area v� RYcl,j�k <br />Grout Inspection By 1 Date S ECTAL ' r`0% <br />Pump Inspection By Date cI WAIVER ReCeiVeY G <br />Soil Boring Inspection By Date Constructed Well DLiSEP 14 2018 r <br />COMMENTS <br />_3M_j0AUUIN COUNTY <br />PE Sc <br />Codes Info <br />Received <br />By <br />Checks <br />Cash <br />Amount <br />Remitted <br />Date <br />Permit/ <br />Service Request # <br />invoice # eILD,;' <br />3 00 <br />Lb <br />W00-5v- <br />EHD 43-06 WELL /PUMP PERMIT <br />8/04/08 <br />