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f <br /> WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232(209)4683420 <br /> NON-REFUNDABL Pr�ERMIT�/� www.sjgov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS Vu r V�� 1�W CR �Y/ZIP r 3 m <br /> CROSS STREET APN / l/ PARCEL SIZE VO. LAND USE APPLICATION# A <br /> m <br /> OWNER NAME PHONE y <br /> OWNER ADDRESS C D CITYISTATE21P -rr <br /> CONTRACTOR PHONE 1J J <br /> CONTRACTOR ADDRESS 9{_e- CRY/STATE21P - �- kk)'? CJ '1y?e6 <br /> SUBCONTRACTORICONSULTANT � r7` YIpit? PHONE <br /> r///�/yyy`/`.7(/, 7106 <br /> SUBCONTRACTORICONSULTANT ADDRESS J J� ✓r� CCrTTY/SSTATE21P f (✓6!C/ <br /> LICENSE �C-57 - C-61 D-09 Other NUMBER [W L EXPIRATION DATE <br /> BILLING PARTY: -;OWNER r[CONTRACTOR _1 SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING:G General Mineral/Coliform Bacteria(4391)❑Dibromochloropropane(4392) ,Arsenic(4393) <br /> INTENDED USE 7 Domestic/Private ❑Irrigation/Agricultural C Industrial ❑Water Quality Monitoring Soil Sampling/Characterization <br /> Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK i New Well 1 Replacement Well i Well Alteration/Modification i i Other <br /> Monitoring Well(s) #of wells r Soil Boring(s) s of borings Geotechnical_ #of borings <br /> _Out-Of-Service Well L Out-Of-Service Well Renewal _l Cross-Connection Repair <br /> New Pump I Pump Replacement G Pump Repair r;Raise Well Casing <br /> WELL CONSTRUCTION / <br /> Drilling Method Mud Rotary Air Rotary \/Auger ❑Cable Tool L Push Point ❑ Other <br /> Proposed Well Depth ';--'SO ft Excavation in diameter Open Bottom Gravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Sched E Steel C Plastic Stainless Steel ii Other <br /> Grout Seal Depth ft .1l Neat Cement(94 lb bag/5-10 gal water) - Sand Cement sack mix/7 gal water <br /> 1 Bentonite(20%solids Other <br /> Grout Placement Method V/Pumped j Free Fall -Other 1 Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑Driller F Pump Contractor l Other <br /> 7 Concrete Pedestal uDlmensions:Width ft Length ft Thick in ❑Christy Box ^Stove Pipe <br /> PUMP 7 Submersible)Turbine it 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 /> MI MUM 48 O R ADVANCE NOTICE REQUIRED FOR INSP IO $-PLEASE CALL(209)953-7 97 <br /> r �, <br /> SIGNED C TITLE J (.� // � DATE / <br /> RE <br /> C�jVE� <br /> UL f 2 ?019 <br /> E V/AQUIN SOU <br /> Ile- y pEPgR L <br /> T <br /> APARTMENT U'711SE NLY /q� / <br /> Application Accepted By Date Area Employee ID# Ak^11IIf <br /> Grout Inspection By V Date Y SPECIAL Well Permit <br /> Pump Inspection By Date - WAIVER Received <br /> Soil Boring Inspection By J14 Date 1 Constructed Well Depth ft <br /> COMMENTS <br /> PE Sc Received Check#I Amount Date Permit/ Invoice# Well ID# <br /> Codes Info Cash Remitted ervice Re uest# <br /> me L50_ 11 IT-11 <br /> EHD43-06 6111/2019 WELL/PUMP PERMIT <br />