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4� <br /> 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 EXPIRES 1 YEAR FROM DATE ISSUED <br /> Joe ADDRESS <br /> 2701 Michigan Ave CITY/ZIP Stockton 95204 <br /> m <br /> CROSS STREET N. Ryde Ave APN 109-360-03 PARCEL SIZE LAND USE APPLICATION# o <br /> OWNER NAME Dominion Life Christian Center PHONE 925-275-1600 w <br /> OWNER ADDRESS 2252 Camino Ramon CITY/STATE/7lP San Ramon, CA 94583 <br /> (CONTRACTOR US Pull Test 818-625-1300 <br /> PHONE <br /> CONTRACTOR ADDRE$5 CITY/$TATE/ZIP 2713 Georgette PI Simi Valley, CA 93063 <br /> ( <br /> SUBCONTRACTOR ` `` C 1� l `s' PHONE <br /> �� yL <br /> "!SUBCONTRACTOR ADDRESS /r IVL` CITY/STATE/ZIP L _ <br /> _ 0J - <br /> 'LICENSE C-57 C-61 D-09 Other NUMBER �V E%PIRATION <br /> DOMESTIC VVEIL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE :DomestirJPnvate Irrigation/Agricultural Industrial Water Quality Monitoring Y Soil Sampling/CharactenzatIon <br /> Public Water System <br /> It Off—t from C.— 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 oil Bonng(s) 1 0 of cohnve Geotechnical—mss of bO gs <br /> Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair <br /> New Pump Pump Replacement Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotn Air Rotary Auger Cable Tool ;Push Point Other <br /> I Proposed Well Depth1;401 ft Excavation in diameter Open Bottom Gravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth It <br /> Well Casing Diameter in Thickness/ auge/ASTM Silted Steel Plastic Stainless Steel Other <br /> Grout Seal Depth eff It Neat Cement(94 1b 6ag/5-10 gal water; Sand Cement sack mix17 gal water <br /> Bentonite 0%solids) Other <br /> Grout Placement Method Pumped Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller Pump Contractor Other <br /> Concrete Pedestal Dimensions.%%hdth It Length tt Thick in Christy Box Stove Pipe <br /> au-_MP Submersible Turbine Other HP Pump Ser 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 ITH THE CALIFORNIA ONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL <br /> WORKER OMPENSA OI LAWS. <br /> I 8 R DVANCE NO E REQUIRED F INSP�CTIPNS-PLEASE CALL(209)95 -7697 <br /> SIGN A TITLE rC'(�Ttt` DATE <br /> I <br /> q4 2©19 <br /> o <br /> I FNT <br /> DEPARTMENT_USE ONLY rr I / <br /> Application Accepted By �� Date �< Area (� Employee ID#S_ / l <br /> Grout Inspection B Date SPECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Inspection By f�Date i Construe d Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#/ Amount PermiV <br /> Codes Into By Cash Remitted Date Service Request 4 Invoice# Well ID'# <br /> 4 - XX <br /> EMO 43-06 revised 4/14/18 n^ ' �/�/��� WELL/PUMP PERMrT <br />