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WELL/PUMP PERMIT <br /> i SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCK-TON CA 95205 (- 20A ti 2Q� <br /> NON-REFUNDABLE PERMIT FOR �'$� <br /> J7 INSPECTIONS EXPIRES 1 YEAR FROM <br /> # E <br /> Joe ADDRESS 7u A //w CALL 209//� 4 953-769 41 CITY/ZIP Zo Q/� <br /> CROSS STREET APN �(y/rq�fr-�/�./!O/�i/•QN����/�/ PA{/RC E(L$►RCE�_ —L/AND USE <br /> E1/APPGUCpJAIJTG/IO{N#�D•'yU,.Gr,�,.t' <br /> yGD caOWNER NAME PHONE <br /> OWNER ADDRESS CITY/STATE/ZIP .100/ <br /> CONTRACTOR 04Vow J 4.m / PHONE r^00 <br /> a7?1�y <br /> CONTRACTOR ADDRESS 7C/ CJ C� �r/4.0"e., J.7" CITY/STATE/ZdP_ J�-O -'e <br /> SUBCONTRACTOR <br /> PHONE <br /> SUBCONTRACTOR ADDRESS CITYISTAATEIZIP �� <br /> LICENSE 7 C-67 *-C-61 D D-09 C Other OV NUMBER 2z 8.�3 ExPIRAnoN D/ <br /> DOMESTIC WELL SAMPLING:❑General Mineral/Coliform Bacteria(4391)L Dibromochloropropane(4392)❑Arsenic(4393) <br /> INTENDED USE JOmestic/Private $Irrigation/Agdcultural D Industrial D Water Quality Monitoring D Sol Sampling/Characterization <br /> ri r'ubiic Water System <br /> If different from Owner. Water System Name Contact Name or Phone Number <br /> TYPE OF WORK D New Well D Replacement Well .1 Well Alteration/Modlfication 7 Other <br /> D Monitoring Well(s) #of wells 7 SOiI Bodng(s) #of borings ❑Geotechnical #of borings <br /> 11 OUt-Of-Service Well -1 Out-Of-Service Well Renewal r Cross-Connection Repair <br /> WELL CONUCTION ew Pum C Pum Replacement D Pum Repair D Raise Well Casing <br /> STR <br /> Drilling Method n Mud Rotary F Air Rotary F Auger n Cable Tool n Push Point n Other <br /> Proposed Well Depth ft Excavation In diameter C 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 D Steel D Plastic ❑Stainless Steel D Other <br /> Grout Seal Depth ft L Neat Cement(94 111 bag/5-10 gal water) a Sand Cement <br /> D Bentonite(20%solids) a Other sackmix/7 gal water <br /> Grout Placement Method D Pumped C Free Fall C Other D Retardant/Accelerator(name) <br /> PEDESTAL Installed By Ll Driller b Pump Contractor L Other <br /> D Concrete Pedestal DDlmenalons:Width J; ft Length It Thick to in D Christy Box _Stove Pipe <br /> PUMP �t tuubmersiblef-Turbine n Other HP Pum Set /'YL <br /> P It Standing Water Level O ft <br /> 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORKWILL 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 /> MINIMUMS 48 P4OUR AD-VANCEN ICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED - R, /y,�/ (� <br /> TITLEDATE 11-.2 G7 <br /> ENT <br /> 'v E® <br /> 9 2018 <br /> IN COUNTY <br /> MENTAL <br /> PARTMENT <br /> EP �RTMENT U E O Y <br /> C <br /> Application Accepted By Date Area <br /> Employee ID# /(/� <br /> Grout Inspection By Date ❑ SPECIAL Well Permit / <br /> Pump Inspection By Date©� �,�J WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE Sc Received Check#/ Amount Permitt <br /> Co Info Cash emitted Date 5 Service Re uest# Invoice# Well ID# <br /> EHD 43-06 revised 4/14116 <br /> WELL RUMP PERMIT <br />