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L <br /> WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 905-6232 (209)468-3420 <br /> NON-REFUNDABLE PERMIT www.sjgov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS O Vv CITY/ZIP m <br /> D <br /> CROSS STREET 7 APN PARCEL SIZE LAND USE APPLICATION# <br /> � '•C/ 'N,VJ cn <br /> OWNER NAME QQ,�,,,��, �1p �+�PHONE �\ Q �9� (nn. <br /> OWNER ADDRESS O, [HJT 2SG7_O CITY/STATE/ZIP vC�� S_ C—R -lS lJL► <br /> CONTRACTOR L'A$c.►9ple ye-jL L 1.0 L,?. PHONE /(� <br /> CONTRACTOR ADDRESS SCM '�U1.U-t'�fI ST• CITY/STATE/ZIPW. J f11yU�N1O, l_F� .9st a I <br /> SUBCONTRACTOR/CONSULTANT ��"-r-> 9I FC-L(f-�E )oc- PHONE <br /> SUBCONTRACTOR/CONSULTANT ADDRESS '7I ?(n Q45 K /-f'V i5 CITY/STATE/ZIPL , C-ft- 9:5-7 6 <br /> LICENSE /C-57 ❑ C-61 ❑ D-09 ❑ Other NUMBER CtSA('11) EXPIRATION DATE 41 <br /> BILLING PARTY: ❑OWNER ❑CONTRACTOR SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING:❑General Mineral/Coliform Bacteria(4391)❑ Dibromochloropropane(4392)❑Arsenic(4393) <br /> INTENDED USE ❑ Domestic/Priv Yfrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring Soil Sampling/Characterization <br /> ❑ Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK ❑ New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other <br /> ❑ MonitoringWells #of wells Soil Boring(s)s #of borings #of borings <br /> ( ) g( )�_ Geotechnical Z <br /> ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> ❑ New Pump ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling MethodMud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool D Push Point ❑ Other <br /> ProProposed Well Depth `, �� <br /> p p _$b ft Excavation �,-g 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 ❑ Steel ❑ Plastic ❑ Stainless Steel ❑ Other <br /> Grout Seal Depth 0 ft Neat Cement(94 lb bag/5-10 gal water) ❑ Sand Cement sack mix17 gal water <br /> ❑ Bentonite(20%solids) ❑ Other <br /> Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other <br /> ❑ Concrete Pedestal❑Dimensions:Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe <br /> PUMP ❑ Submersible❑ Turbine ❑ Other HP Pump Set ft Standing Water Level fLI <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 /> !t1MPLEASEU VANCE NOTICE REQUIRED FOR INSPECTIONS ` CALL(209)951 97 <br /> SIGNED TITLE �SC-L V CN6 10 C F DATE ( lick <br /> F Q <br /> M ry <br /> T <br /> AR M ENT USE OpN LY <br /> Application Accepted By ate /t( ( / Area Employee ID# <br /> Grout Inspection By Date Ci PECIAL Well Permit <br /> Pump Inspection By Date L WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#/ Amount Permit/ <br /> Codes Info B ash a itte Date Service Re uest# Invoice# Well ID# <br /> Zl <br /> EHD43-06 6/11/2019 /� � /,��/ WELL/PUMP PERMIT <br />