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SCANNED <br /> WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 186a 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 /> Joe ADDRESS 1114960 Crrym LODI,CA 95242 m <br /> oDp <br /> CROSS STREET APN 055-020-020-@0@ PARCEL SIZE 12.0 LAND USE APPLICATION 1t 612 'P� <br /> OWNER NAME GRINDSTONE JOE ASSOCIATION PHONE (650)279-0242 H <br /> OWNER ADDRESS 1029 N COUNTRY CLUB BLVD. Cm/STATEOP STOCKTON,CA 95204 A <br /> CONTRACTOR DREW 8i HEFFNER WATER WELLS 8 PUMPS _ PHONE (559}645-2483 _._ C5 <br /> CONTRACTOR ADDRESS 26452 AVENUE 17 112 _—_ CITYISTATEmP MADERA,CA 93638 _ __— <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STA7E21P = <br /> LICENSE SIC-57 C-61 D-09 Other NUMBER 1003754 EXPIRATION DATE 05/31/2021 D <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391)%/Dibromochloropropane(4392)VArseroc(4393) <br /> INTENDED USE DomesticlPnvate Irrigation/Agricultural ai Wafer Quality Monitoring Sod Sampling/Charac!enzation � <br /> Public Water System _ --- - to <br /> L If different from Owner Water Sys om Nrme CurNan Name nr PAone Numnur CD <br /> - <br /> TYPE OF WORK New Well Replacement Well Well AteralmnlModitation OthtX_. _-____-_ ..--___._ O <br /> Monitoring Wells) At Of wells Sod Boring;s1_ e ni 1tl1'ay' Geolechnlcal O <br /> --- <br /> Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair <br /> _VNeW Pump Pump Replacement Pump Repair Raise Well Casing D <br /> WELL CONSTRUCTION <br /> Drilling Method VMUd Rotary Fur Rotary Auger Cable Tool Push Point Other N <br /> Proposed Well Daptn 200 h Excavation 12 in diameter Open Bottom Gravel Pack/Gravel Size a aa+.r,rs in diameter 4" <br /> N <br /> Conductor Casing in diameter I Conductor Casing Depth ft <br /> Well Casing Diameter A-in ThlckgpSSPV-auge/ASTM Schad SDR 17 Steel VP!astic Stainless Steel Other_ _ - <br /> Grout Seal Depth Of-al Cement(94 lb bag/5-10 gat water) Sand Cement_ 10.3 sack m,x1'7 gal water <br /> Bentonite(20%solids) Other ----------- I i <br /> i <br /> Grout Placement Method VPumpecl Free Fall Other Retardant I Accelerator(name) <br /> E&QLSTAL In¢tailed By Driller Pump Contractor Other <br /> V Concrete Pedestalybimensions Wroth_.±_ft Length a It Thick + m Christy Boz Stove Pipe <br /> PUMP VSubmersitle T r HP Pump Set as it Standing Water Level f1 <br /> I H THAT I VE PREPARED S APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> AQUIN COUNTY RDIN CES, STATE LAWS, D RULES AND REGULATIONS. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE 19 <br /> Q <br /> URRENT AND ACTI THE CALIFORNIA C NTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL <br /> ORKERS COMPENS 10 LAWS. <br /> MINIMUM 4 FIO R ADVANCE REQUIRED FO NSPECTIONS-PLEASE CALL(2095 7697 <br /> TITLE � DATE 1GNED � -- '-----I - - -- <br /> AYMENT <br /> _ - ECEIVED <br /> - - - -� 2 5 2019 <br /> A JOAQUIN COUNTY <br /> ------------ T -4 VIROMMENTAL <br /> E LTH OEPARTMENI <br /> ESP RTMENT U E O LY <br /> TTI <br /> Application Accepted By - _ hale',_ Arca _f.�J_e�✓ L-mplo yee IDtF/1�/';r vw L�(frJ <br /> n �� t� � Oste ei`SSSSSSPECIAL Well Permit <br /> Grout Inspection By -. "7,�> .K-��� <br /> Pump Inspection By -____ hale- --- _ WAIVER Received <br /> Sod Boring Inspection By Da _ Constructed - <br /> Well Depth t <br /> 1.1 <br /> Q TShWL -/4Tt-.:-jAf'r"f /� <br /> PE SC ceived CheckllI Amount Permit! Y Invoice q <br /> ReWell IDs 0 JU r <br /> odes Info <br /> Cash Remitted at ervice Re est III <br /> _ <br /> C <br /> 4r --- <br /> IT <br /> r•rC.<3-75,e,s^c+,ta„5 r �l ey Cl V-,— `V V ._— - __ .... WELL PUMP PERMI' <br /> bo ' — <br /> of ��a f— l(, ' tt l,?W l 0 - SLS- <br />