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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1866 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 /> 1 A' /^ N <br /> JOB ADDRESS VY <br /> \'/�[� /wQlot 6 'foy VCO CINizIIp 0 <br /> CROSS STREET APN ARCEL SIZE 7/_"/ AND USE APPLICATION# <br /> OWNER NAME r �T PHONE rwn, <br /> OWNER ADDRESS Z <br /> CITY/STATEP <br /> ([' <br /> CONTRACTOR I�IO;...Te A10AP <br /> 1 (� .` 1 (+lPHO.N/E ` {'/� <br /> CONTRACTOR ADDRESS <br /> /A 44L'k' �USri jRncQ 1. 1/5/ CITY/STATE21P k'10Crtt/%� �ikJ/J I+,(J <br /> SUBCONTRACTOR 1,j� t 1'1n� PHON��11 <br /> SUBCONTRACTOR ADDRESS -G 4yP C3. r n "A CITY/STATE/ZIP W. CuLYA1rfrol p <br /> LICENSE V57 D C-61 _- D-09 D Other NUMBER EXPIRATION DATE <br /> DOMESTIC WELL SAMPLING:D General Mineral/Coliform Bacteria(4391)L Dibromochloropropane(4392)Li Arsenic(4393) <br /> INTENDED USE D Domestic/Private D Irrigation/Agricultural D Industrial D Water Quality Monitoring oil Sampling/Characterization <br /> D Public Water System <br /> Bdiffemnt from Owner. Water System Name Contact Name or Phone Number <br /> TYPE OF WORK D New Well 7 Replacement Well D Well Alteration/Modification D Other <br /> D Monitoring Well(s) #of wells D Soil Borings) #of borings p,'Geotechnical41 #of borings <br /> D Out-Of-Service Well D Out-Of-Service Well Renewal D Cross-Connection Repair <br /> D New Pump D Pump Replacement 7 Pump Repair C Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method D Mud Rotary C Air Rotary D Auger D Cable Tool Lr'Push Point C Other <br /> Proposed Well Depth16jft Excavation in diameter 7 Open Bottom D Gravel Pack/Gravel Size in diameter <br /> D Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Schad J Steel J Plastic u Stainless Steel u Other <br /> Grout Seal Depth It VNeat Cement(94 Ib bag15-10 gal water) 7 Sand Cement sack m/x17 gal water <br /> I i Bentonite(20%solids) i Other <br /> Grout Placement Method J Pumped C Free Fall D Other C Retardant/Accelerator(name) <br /> PEDESTAL Installed By 7 Driller D Pump Contractor 7 Other <br /> n Concrete Pedestal nDlmensions:Width It Length It Thick in F Christy Box F Stove Pipe <br /> PUMP D Submersible?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. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS PA <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'48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 �® <br /> SIGNED ._.fir' TITLE Jtnj, • 'ry DATE N <br /> 2 2019 <br /> IR0NMi�C0UN� <br /> �FpgR�FNT <br /> tE ARTMENT LIAE VNLY <br /> Application Accepted By Date 2 Area Employee ID# <br /> Grout Inspection By Date SPECIAL WeII Permit <br /> Pump Inspection By _ DateWAIVER Received <br /> Soil Boring Inspection By Date 1711 1,t/ Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#/ Amount Permit/ <br /> d s Into By Cash Remitted Date S ce a uest# Invoice# Well ID# <br /> EHD 43-06 revised 4114118 N WELL/PUMP PERMn <br /> l D(� l H <br />