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• WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 <br /> NON-REFUNDABLE PER/MIT CALL 209 953-7697 FOR INSPECTIONS I EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 1 r U Cq Z q CITY2IP Lod , 952% <br /> m <br /> CROSS STREET APN ARCEL SIZE LAND USE <br /> QAPPLICATION <br /> J-7#4 <br /> OWNER NAME K e v I h ` 1\ PHONE <br /> OWNER ADDRESSI��"-\`'� (� {' CITY/STATEMP <br /> \V <br /> CONTRACTOR G I 1 t 1 1-�r t 11 t o^1 l/,P,HONE 3�9 - ?-7-79 <br /> -7 79 <br /> CONTRACTOR ADDRESS -O G X t� QTY/STATE21P v,)��I P 'I S/b 3 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> 1 7 <br /> LICENSE i,C-57 YrC-61L D-09 L Other NUMBER 2� 1 7� . EXPIRATION DATE <br /> DOMESTIC WELL SAMPLING-X General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392)!.]Arsenic(4393) <br /> INTENDED USE ><Domestic/Private i-Irrigation/Agricultural L'Industrial L Water Quality Monitoring ❑ Soil Sampling/Characterization <br /> Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK �K New Well ❑Replacement Well ❑Well AReration/Modification f i Other <br /> i7 Monitoring Wells) #of wells !J Soil Borings) #of borings 1 Geotechnical #of borings <br /> Out-Of-Service Well L Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> ivcw"wTi _;RuiTi Raplal.ai—iiClll J rUlll ria aii R <br /> Raise vveu Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary Air Rotary L Auger'�T Cable Tool -Push Point Other <br /> Proposed Well Depth�_ft Excavation in diameter i7 Open Bottom Gravel Pack/Gravel Size (/4- in diameter <br /> i Conductor Casing in diameter / Conductor Casing Depth It <br /> Well Casing Diameter in Thickness/Gauge/ASTM Schad C li;?C L G Steel KPlasbc n Stainless Steel i Other <br /> Grout Seal Depth )(No It Neat Cement(94 111 bag/5-10 gal water) ASand Cement sack mixl7 gal water <br /> Bentonite(20%solids) Lj Other <br /> Grout Placement Method XPurnped _.Free Fall --Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller : Pump Contractor Other <br /> Concrete Pedestal.:Dimensions:Width J7 ft Length S ft Thick in i Christy Box I Stove Pipe <br /> PUMP Submersiblei-I Turbine 1 1 Other HP Q Pump Set It S G ft Standing Water Level U 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 <br /> �48•�HOUR <br /> �ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697Q <br /> SIGNED � -G / /wV�'K~' TITLEy 1 C f- PreS'1 C ` Y) 1 DATE I" <br /> C <br /> Cp <br /> PqY4,Enrr <br /> RECE�VEp <br /> tP062018 <br /> JOAQUIN COU <br /> IttI RONM COUNTY <br /> AL+4 <br /> PA TMENT US N Y THOEPARTMENT <br /> Application Accepted By ate Area 4A-+— Employee lD# <br /> Grout Inspection By Data SPECIAL Well Permit <br /> Pump Inspection By ) Date r WAIVER Received <br /> Soil Boring�Ins e(ctyion By �,r Date Constructed Well Depth ft <br /> COMMENTS s-�Ct" "Al-11 7 ?M&A 1A t f/'/ C� - <br /> PE SC Received Check#/ Amount Date Permltt Invoice# Well ION <br /> Codes fc By Cash Remitted Service Request# <br /> Lt' qq 10 <br /> 14p-1g WPOO 5 l l <br /> -1 P0)-5 W <br /> EHD 43-08 revised 4/14/18 WELL/PUMP PERMIT <br />