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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 PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRJES�1 YEAR FROM DATE <br /> ISSUED <br /> JOB ADDRESS <br /> lGd1T4 Crrv21P S�o�.k •J!il m <br /> CROSS STREET I M 1 r 0 r APN O(�y 'L T PARCEL SIZE? LAND USE APPLICATION# p <br /> m <br /> OWNER NAME �/-7 PHONE T N <br /> OWNERADDRESSq `• V / CITY/STATE/ZIP, V <br /> CONTRACTOR K) 1.11W/e.- A I <-- C,PPH,O'NEE I+ /' S 4 �'1^3— <br /> CONTRACTOR ADDRESS 2061 Ar01 1—At r f'!' QC. JN.I��Y/STATE2IP SItr4 � ( A 1'�}���V�10 <br /> SUBCONTRACTOR V Z`V�/�/ 10P,1//�l�I {�� /�.oQ �) C.JPHHO�NE :2— ter'9�g4�(T' <br /> SUBCONTRACTOR ADDRESS 3&96 0,44 \ N eC k {/r. CITY/STATE2IP t]�CJ�i�j(�\ ` A t J 21 J <br /> LICENSE -57 ❑C-61 ❑ D-09 Other NUMBER 0 EXPIRATION DATE <br /> DOMESTIC WELL SAMPLING:CI General Mineral/Coliform Bacteria(4391) .Dibromochloropropane(439 )_I Arsenic(4393) <br /> INTENDED USE L Domestic/Private i Irdgation/Agricultural 1 i Industrial a Water Quality Monitoring VSoil Sampling/Characterization <br /> I Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK t_ New Well 7 Replacement Well ❑Well Alteration/Modification J Other <br /> IF Monitoring Well(s) #of wells U Soil Boring(s) #of borings Geotechnical 4 of borings <br /> Out-Of-Service Well I!Out-Of-Service Well Renewal L Cross-Connection Repair <br /> F New Pum Pump Replacement F Pump Repair -1 Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method I Mud Rotary n Air Rotary fillAuger i Cable Tool n Push Point Other <br /> Proposed Well Depth'2,�rft Excavation_8 in diameter G.Open Bottom i Gravel Pack/Gravel Size in diameter <br /> Fl Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_in ThicknessZauge/ASTM Sched i i Steel i 1 Plastic i Stainless Steel i Other <br /> Grout Seal Depth It Neat Cement(94 lb bag/5-10 gal water) n Sand Cement sack mix/7 gal water <br /> ii Bentonite(20%solids) i Other <br /> Grout Placement Method i_ Pumped Free Fall F Other I-i Retardant/Accelerator(name) <br /> PEDESTAL Installed By i Driller Pump Contractor i_i. Other <br /> Concrete Pedestal CDimensions:Width It Length It Thick in L Christy Box i I Stove Pipe <br /> PUMP C Submersible s 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 /> MIANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)9/53-7697 <br /> SIGNED � TITLE �(D�LOn�� DATE <br /> � qIk <br /> °�eQ 06 �® <br /> ti lipqQ41, `74919 <br /> OF qRF��CN� <br /> MFNr <br /> PA TMENT U E NL <br /> i <br /> Application Accepted By ate Area Employee ID# <br /> Grout Inspection By Date ECTAL ell Permit <br /> Pump Inspection By 4 Date 1 WAIVER Received <br /> Soil Boring Inspection By Date i Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Co I f Ca$h Re d Service Request# <br /> EHD 43-06 revised 4/14/18 Ile WELL/PUMP PERMIT <br />