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e , <br /> WELL/PUMP PERMIT <br /> 111 <br /> SAN JOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1$$$EAST HAZELTON AVENUE-STOCKTON CA 95205- 4 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 7 YEAR FROM DATE ISSUED <br /> r� a <br /> JOB ADDRESS n/I qbq Qy P __ - CITYIZIP l !/1 m <br /> If <br /> CROSS STREET uPAO <br /> —"TI RCEL SIZE L # <br /> _LAND USE APPLICATION O <br /> OWNER NAME ENOL KA✓hps PHONEJ'79 1x73—`Z.,�(�I m <br /> 1 <br /> OWNER ADDRESS 21 I .� Pw.0 IC711*:)/l P CITY(STATEIZIP �QoatjT e <br /> 7�/�. <br /> CONTRACTOR U6VJ r-O&AII �er�� .�1f'rI,gZG��O✓I �/�PHONE20 �j' �,�19—�07'rj <br /> CONTRACTOR ADDRESS !.J!OD s �.c k�lU rl� CIN/STATE/Z1P 1 r <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATEOP <br /> LICENSE ❑C-57 C C-61 ❑D-09 D Other NUMBER 6p Z EXPIRATION DATE Z-42-c7 <br /> DOMESTIC WELL SAMPLING:❑General Mineral/Coliform Bacteria(4391)❑Dibromochloropropane(4392)❑Arsenic(4393) <br /> INTENDED USE C Domestic(Private ❑Irrigation/Agricultural D 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 D New Well 0 Replacement Well El Well Afteration/Modification C Other %i jWEN-r <br /> 0 Monitoring Well(s) #of wells C Soil Boring(s) #of boring' 0 Geotechnical #of borings E�V <br /> 0 Out-Of-Service Well C Out-Of-Service Well Renewal C Cross-Connection Repair y ED <br /> New Pump ❑Pump Replacement D Pump Repair C Raise Well Casing <br /> WELL CONSTRUCTION 1 L 1� 2019 <br /> Drilling Method D Mud Rotary C Air Rotary 0 Auger C Cable Tool ❑ Push Point ElOther <br /> Proposed Well Depth ft Excavation in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in it QUIN <br /> C Conductor Casing in diameter / Conductor Casing Depth COUNTY <br /> ft I ONM CO <br /> AL <br /> Well Casing Diameter,In Thickness/Gauge/ASTM Schad ❑Steel C Plastic D Stainless Steel C Other HEALr EPARTM NT <br /> Grout Seal Depth ft C Neat Cement(94 lb bag/5-10 gal water) D Sand Cement sack mixr7 gal water <br /> ❑Bentonite(20%solids) C Other <br /> Grout Placement Method L Pumped C Free Fall D Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By D Driller t'hmp Contractor ❑ Other <br /> ❑Concrete Pedestal CDimensions:Width ft Length ft Thick n :1 Christy Box [I Stove Pipe <br /> PUMP ubmersibleC Turbine ❑Other HP__Z — Pump Se 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 15 <br /> CURRENT AND ACTIVE WITH THE qALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT i AM IN COMPLIANCE WITH ALL <br /> WORKERS GOMPENSA VJVANCE <br /> MINIM HO NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)9953-7697 <br /> SIGNED TITLE .r— DATE <br /> FT <br /> PA TMENT U E O���LY <br /> Application Accepted By Date-C Area Employee]D#141 <br /> Grout Inspection By Date ❑ PECIAL Well Permit <br /> Pump Inspection By ate "� l� ❑ WAIVER Received <br /> c <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE I SC Received Check#/ Amount Permit/ <br /> C Info Cash Remitted Date Service Re u st# Invoice# Well ID# <br /> ZW51 4W S4— <br /> EHO4309 9101118 8g7'�7oq 4 WELL/PUMP PERMIT <br />