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WELL/PUMP PERM ITW�":R r5X11'"1 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FyyROM DATE ISSUED <br /> JOB ADDRESS NW (' Pkwy. CIN/ZIP�gLod1 � Lt(,'l� j <br /> o <br /> Re. <br /> CROSS STREET�`,(. EIIAP1N D DS . 'PARCEL SIZE x•31 LAND USE APPLICATION <br /> OWNER NAME ,-c�'L��//1Y�Y1(J+�`�tA�1LaiY11'�1 AU-11IIIIS 4^t A^ / ,,.,,PIHONE �^•'(�1f-' /1��'7 l�IV rNa <br /> OWNERADDRESS -LW J`yi�•�\�d\�"11 H-11(9,.,�! CTE / �, CITY/STATE/ZIP WtJt (� ?`/Jj��'T? <br /> CONTRACTOR VA\,(.BHN t\ �'l] �7 Z(;'t�t17� P`HONEg1 J'1-/-1434 <br /> �t`(�� / <br /> CONTRACTOR ADDRESSipso, �L-f1(Q-ih,,x -t(A CITY/STATE/ZIP t'"0}1/M+Ir ft, <br /> SUBCONTRACTOR UwDi \11 C e PHONE /y-l(� <br /> SUBCONTRACTOR ADDRESS I(. - f I'DCITYISTATE/ZIP AL `( �L <br /> LICENSE C-57 C1 C-61 ❑0-09 C Other NUMBER 11 030' ExPIRATION DATE <br /> / <br /> DOMESTIC WELL SAMPLING:n General Mineral/Coliform Bacteria(4391)n Dibromochloropropane(4392)n Arsenic(4393) <br /> INTENDED USE 7 Domestic/Private u Irrigation/Agricultural ❑Industrial C Water Quality Monitoring Soil Sampling/Characterization <br /> 7 Public Water System <br /> If different from Owner. Water System Name Contact Name or Phone Number <br /> TYPE OF WORK 7 New Well C Replacement Well ❑Well Alteration/Modification ❑Other <br /> 7 Monitoring Well(s) #of wells D Soil Bodng(s) #of borings Geotechnical #of borings <br /> 7 Out-Of-Service Well ❑Out-Of-Service Well Renewal 7 Cross-Connection Repair <br /> -1 New Pum -1 Pump Replacement n Pump Repair 5 Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method -1 Mud Rotary -1 Air Rotary YAuger -1 Cable Tool n Push Point n Other <br /> Proposed Well Depth 15�-&10 ft Excavation_ 1`�in diameter L Open Bottom a Gravel Pack/Gravel Size in diameter <br /> 7 Conductor Casing in diameter I Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Schad C Steel Plastic C Stainless Steel ❑Other <br /> Grout Seal DepthI 5j 40 U ft Neat Cement(941b bag/5-10 gal wafer)! L,Sand Cement sack mix/7 gal water <br /> Bentonite(20%solids) 17 Other ,1r�"�/�R rid,1 U11q Tip 1 <br /> Grout Placement Method 7 Pumped )<Free Fall Other V.1111Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller I I Pump Contractor i Other <br /> 7 Concrete Pedestal=Dimensions:Width ft Length ft Thick in ❑Christy Box C Stove Pipe <br /> PUMP -1 Submersible Turbine -1 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(209J)953-7697 <br /> SIGNED <br /> SIGNED TITLE fl#-F- DATE <br /> ( <br /> REIV-r <br /> ' 2 2018 <br /> IT TT <br /> N ENTgL TY <br /> P RTMENT <br /> EP RTMENT UE N L Y <br /> [[1 <br /> Application Accepted By Date Area Employee ID# L? <br /> Grout Inspection By Date ❑ SPECIAL Well Permit / <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection By Date I1 110 Constructed Well Depth ft <br /> COMMENTS IQetri N. 4�� f eLln <br /> PESC I Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> _Codes Info B Cash Remitted Service Re uest# <br /> 0 58bbo16molw— <br /> �v - U <br /> 0 <br /> EHD 43-06 revised 4/14/18 WELL/PUMP PERMIT <br />