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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)468.1420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS I U Cc,a VC Z P CITYQIP L Ud , G S 2 1 <br /> m <br /> pts Oe <br /> CROSS STREET -rkrCO­S S' YN APN ZSyy ARCEL SIZE LAND USE APPLICATION#4 2 <br /> OWNER NAME i `VMI ` \\ PHONE <br /> OWNER ADDRESS \ '0 o -``'t (� L CITY/STATE(LP <br /> CONTRACTOR V&11 t 7 (J1-'r 1 11 1 n 1 `/,P,HONE 3�9p- 2-7-79 <br /> CONTRACTOR ADDRESS ?•O 90 A 412 CITY/STATE/ZIP v,1� C r` q 5(-,3 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> ZaaLLICENSE �,C-57 �i C-61 Ll 0-09 r Other NUMBER EXPIRATION DATE <br /> DoMEsnc WELL SAMPUNG.A General Mineral/Coliform Bacteria(4391)_=Dibromochloropropane(4392)L.Arsenic(4393) <br /> INTENDED USE Domestic/Private ::-Irrigation/Agricultural -i Industrial -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 Afteration/Modification Other <br /> -Monitoring Well(s) #of wells L Soil Boring(s) #of bonngs L_Geotechnical #of bodngs <br /> Out-Of-Service Well Out-Of-Service Well Renewal L Cross-Connection Repair <br /> ,Naw Punri _ PuimiReplacemie 1t 1.Pu rl I Raise Afell"asi g <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary ❑Air Rotary i i Auger r Cable Tool ❑ Push Point Other <br /> Proposed Well DepthJ7,C; ft Excavation_I� in diameter r_i Open Bottom Gravel Pack/Gravel Size V 4- in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth It <br /> Well Casing Diameter(--02-in Thickness/(3auge/ASTM Sched c�;?ct, ❑Steel XPlastic _i Stainless Steel i i Other <br /> Grout Seal Depth )b0 it Neat Cement(94/b bagl5-10 gal water) S Sand Cement sack mix/7 gal water <br /> L:Bentonite(20%solids) Other <br /> Grout Placement Method XPumped ?Free Fall G Other 7i Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller i-Pump Contractor Other <br /> Concrete Pedestal :Dimensions:Width 5 It Length S it Thick in Christy Box _Stove Pipe <br /> PUMP VSubmersible Turbine C!Other HP Q Pump Set It 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 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MINIMUM 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED�L/"�`� w�/'✓"x'�' TITLE \, 1 C-e- ?ces 1 L�\` � DATE JW <br /> C <br /> CD <br /> L ` <br /> SECSENT <br /> EIVED <br /> EP 062018 <br /> JOA COON <br /> RONMENZA 7Y <br /> P` T M E N T U S N Y J����//�/��7'H DEPMTMENT <br /> Appfication Accepted By ate Area '�q Empioyee Oi w / <br /> Grout Inspection By Date 9 11:01j& 1 SPECIAL Well Permit <br /> Pump Inspection By ) Date WAIVER Received <br /> Soil Boring Ins ection By Date Constructed Well Depth ft <br /> COMMENTS C—IA IA t,!1/ (jr- <br /> PE SC Received Check#/ Amount Permit) <br /> odes fo By Cash Remitted Date Service Request# Invoice# Well ID# <br /> C <br /> 0a ��(p <br /> 40-Ag 0 O _U ILA-1 <br /> o -I \,JPOJ tO <br /> EHC 4M6 revised 4/14/18 WELL/PUMP PERMIT <br />