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t` t <br /> WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 <br /> NON-REFUNDABLE P1ERMItT� CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS <br /> /A 1A N \. W\`5011 UrG \ CrrvmP � m <br /> rrr+ c D <br /> CROSS STREET APN �r\t.A AA PARCEL SIZELAND USE APPLICATION# z <br /> OWNER NAME PHONE m <br /> OWNERADDRESS CITY/STATE/ZIP <br /> CONTRACTORVt!g/n\�I�FYJ\LLC/r + 'PHONE r' <br /> CONTRACTOR ADDRESS '/n� IDYtT- 'r 1'Or 1 � � CITY/STATE/ZIP `/w k0CX is <br /> SUBCONTRACTOR D)IA Z^ ) PHONE(`sN�!'�^- 1.), <br /> SUBCONTRACTOR ADDRESS f1Yt S.n /\ fw' ye,K by. CITYI$TATE/ZJP 'A.Aitan/CA161521 <br /> ' 5 <br /> LICENSE ieC-57 ❑C-61 C D-09 ❑Other NUMBER EXPIRATION DATE <br /> DOMESTIC WELL SAMPLING:❑General Mineral/Coliform Bacteria(4391)C Dibromochloropropane(4392)D Arsenic(4393) <br /> INTENDED USE D Domestic/Private E Irrigation/Agricultural E Industrial E Water Quality Monitoring oil Sampling/Characterization <br /> E Public Water System <br /> If different from Owner. Water System Name Contact Name or Phone Number <br /> TYPE OF WORK E New Well 7 Replacement Well D Well Alteration/Modification D Other <br /> 0Monitoring Weil(s) #of wells 0 Sail Boring(s) #ofbofinga GeotechnicalZI #of borings <br /> ❑Out-Of-Service Well D Out-Of-Service Well Renewal D Cross-Connection Repair I <br /> D New Pum E Pum Re lacement :1 Pum Re air E Raise Well Casin <br /> WELL CONSTRUCT,IO�N/�fN <br /> Drilling Method ud Rotary E Air Rotary f Auger E Cable Tool C Push Point E Other <br /> Proposed Well Depth It Excavation in diameter 7 Open Bottom E Gravel Pack/Gravel Size in diameter <br /> D Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_in Thickness//G/Gauge/ASTM Schad J Steel J Plastic u Stainless Steel U Other <br /> Grout Seal Depth ft X..t Cement(94 Ib bag15-10 gal water) J Sand Cement sack mixfl gal water <br /> I I Bentonite(20%solids) I Other <br /> Grout Placement Method 1901"lumped L Free Fall E Other C Retardant/Accelerator(name) <br /> PEDESTAL Installed By 7 Driller E Pump Contractor 7 Other <br /> n Concrete Pedestal rlDimensions:Width it Length ft Thick in E Christy Box E Stove Pipe <br /> PUMP D Submersible E Turbine 7 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. 1 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 HOU ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)9)53-7697 <br /> SIGNED TITLE GVI�1`�C�-y DATE �I e <br /> All <br /> c* 7VFD <br /> 0? 2419 <br /> iN C� <br /> U <br /> A MENT US O%LY �FpgRHTA� <br /> Application Accepted By Date ` Area Employee ID#�FNT <br /> Grout Inspection e Date ❑ SPECIAL Well Permit <br /> P Y <br /> Pump Inspection By Date I ❑ WAIVER Received <br /> Soil Boring Inspection By Date / Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#/ Amount Permit/ <br /> odes Info B Cash emi d Date ervlce Re st# Invoice# Well ID# <br /> 15, <br /> EHD 43-06 revised 4114/18 /`i O ��'4 -7 WELL)PUMP PERMIT <br />