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WELL/PUMP PERMITW�<A*0;�r <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)4683420 <br /> NON-REFUNDABLE PERMIT CALL(209 953-7697 FOR INSPECTIONS / EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS NW Carer L26wcm VA44^I�v(10)r�S�jp, Pk WY_ Gaya,, 1�Od�, ���"[� m <br /> �� c <br /> CROSS STREET L APN ARCEL SIZE It LAND USE APPLICATION# QQ A <br /> OWNER NAME //k (` l ,�PfHONE -^'a1- <br /> OWNER ADDRESS ,IAW J M1�\� ,��/n_ £!� M CITY/STATE/ZIP r odf64, 15Z4 <br /> CONTRACTOR �� �, Som d, PHONE"II -In-14,-1('-[Q <br /> CONTRACTOR ADDRESS LD50 1n'cr\t(VA• CITY/STATE/ZIP r-..t'�►(,Vt'tMIt'l3s7 <br /> /L-A 1 <br /> SUBCONTRACTOR r ` `I C, PHONE -1 1/0-91-00 <br /> SUBCONTRACTOR ADDRESS 1_ �C/RY/S/T'�ATE21P I [{ L <br /> LICENSE C-57 ❑C-61 -. D-09 L Other NUMBER -'fes V EXPIRATION DATE 1 [� <br /> DOMESTIC WELLSAMPUNG:l General Mineral/Coliform Bacteria(4391)-Dibromochloropropane(4392)1 Arsenic(4393) <br /> INTENDED USE _-Domestic/Private -Irrigation/Agricultural Industrial Water Quality Monitoring _SOil Sampling/Characterization <br /> I Public Water System <br /> If different from Owner Water System Name Contact Name or Phone Number <br /> TYPE OF WORK New Well -.Replacement Well -Well Alteration/Modification Other <br /> Monitoring Well(s) #of wells -i Soil Boring(s) a of borings Geotechnical n of borings <br /> Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair <br /> New Pum -Pump Replacement Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary Air Rotary XAuger Cable Tool -1 Push Point n Other <br /> Proposed Well Depth I5 ko 2fExcavation I�� <br /> 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 Schad Steel Plastic - Stainless Steel Other <br /> Grout Seal Depth 40 7,0 ft Neat Cement(941b bagl5-10 gal water) Sand Cement sack mix/7 gal water <br /> Bentonite(20%solids) -Other r Min-��K — <br /> Grout Placement Method Pumped Free Fall G Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller Pump Contractor Other <br /> -Concrete Pedestal Dimensions:Width ft Length It Thick in Christy Box Stove Pipe <br /> PUMP Submersible- Turbine �Other HP 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 /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MINIMUM 48 H UR AD NCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-76977 <br /> SIGNED r TrrLEgLtr DATE 1 1-Z-t11U <br /> rr <br /> MENT <br /> E/VED <br /> 2 2018 <br /> NJ <br /> Ti COE VV ENTAL N <br /> EP RTMENT USE N L Y ARTMENT <br /> Application Accepted By1 A Date L! Area O Employee ID# � <br /> Grout Inspection By`4 Date SPECIAL Well Permit _01-6J <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Inspection By Date 110 10 Constructed Well Depth ft <br /> COMMENTS <br /> / PE SC Received Che Amount Permitl <br /> G b5V Z bo Codes Info B Cash emitted Date Service Re est# Invoice# Well ID# <br /> i 51554 11/413 <br /> EHD 43-06 revised 4/14/18 WELL/PUMP PERMIT <br />