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1 <br /> WELUPUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 <br /> NON-REFUNDABLE PERMIT r ;_ALL(2091953-7697 FOR INSPECTIONS / EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 1 O I gtrZ1140 CnY/z'PP L CA_ �✓' b�s <br /> CROSS STREET L APN C27r, 7-00-� PARCEL SLLAND USE APPLICATION# p <br /> OWNER NAME ^v` �+ PHONE <br /> \ �C <br /> OWNER ADDRESS o 7Ee 40 111 ��� CI Y/STATE/ZIP `7 / 9 J <br /> CONTRACTOR Kleinfelder PHONE (209)948-1345 <br /> CONTRACTOR ADDRESS `22001 Arch Airport Road,Suite#11`00 CITY/STATEIMP Stockton/CA/95206 `y/ <br /> SUBCONTRACTOR V ✓ 1133 <br /> ?7 r/,- I7, c, �nPHONE J)�6 //v��—7 W <br /> SuacoNTRACTTOR ADDRESS 1 I✓J k lC Kf� CITYISTATE/ZIP ( �I� � I 6 <br /> 3 L <br /> LICENSE NC-57 ❑C-61 ❑D-09 D Other• r, v NUMBER J290 EXPIRATION DATE ® ,2 R0 <br /> DOMESTIC WELL SAMPLING:-General Mineral/Coliform Bacteria(4391)- Dibromochloropropane(4392)7 Arsenic(4393) <br /> INTENDED USE 0 Domestic/Pdvate ❑Inigation/Agricultural 0 Industrial ❑Water Quality Monitoring '%Soil Sampling/Characterization <br /> ❑Public Water System <br /> N dN mnt from Owner. Water System Name Contact Name or Phone Number <br /> TYPE OF WORK ❑New Well ❑Replacement Well 0 Well Alteration/Moci fication (71 Other <br /> ❑Monitoring Wallis) #of wells ❑SoilBodng(s) #ofborings %Geotachnical _#of borings <br /> 0 Out-Of.-Service Well ❑Out-Of-Service Well Renewal 0 Cross-Gonnection Repair <br /> ❑New Pump ❑Pump Re lacement ❑Pump Repair 0 Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method IN Mud Rotary ❑Air Rotary 1N Auger ❑Cable Tool ❑Push Point ❑ Other <br /> Proposed Well DepthW-9�_ft Excavation in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter <br /> 0 Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Dlameter_in Thickness/Gauge/ASTM Sched 0 Steel ❑Plastic 0 Stainless Steel ❑Other <br /> Grout Seal Depth ft 14 Neat Cement(94 Ib bagV5-10 gal water) ❑Sand Cement sack ma/7 gal water <br /> ❑Bentonite(20%solids) ❑Other <br /> Grout Placement Method I@ Pumped ❑Free Fall 0 Other 0 Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑ Other <br /> ❑Concrete Pedestal:]Dimensions:Width ft Length ft Thick In 0 Christy Box 0 Stove Pipe <br /> PUMP ❑Submersible❑Turbine ❑Other HP Pump Set It 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 24 H06R ADVANCE NOTICE REQUIRED FOR INS CTIONS-PLEASE CALL(209)j953-7697 <br /> SIGNED TITLE J rJ� DATE / <br /> vNr <br /> F® <br /> 2018 <br /> J <br /> iI <br /> COON <br /> NTq� <br /> TMENT <br /> D/7 RTMENTLY <br /> Application Accepted By v r Date 10U ENArea Employee ID# V/y <br /> ) <br /> Grout Inspection By CA AZ Data ❑ SPECIAL Well Permit <br /> Pump Inspection By ' ) � Date� ❑ WAIVER Received <br /> Soil Boring Inspection By Yom/ L Date f l Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#/ Amount Data Permit/ Invoice# Well[DO <br /> Codes Info Cash Remitted Service Re uest <br /> EHO43-06 6(01116 i/I �/���/ WELL/PJMP PERMIT <br />