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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232(209)468-3420 <br /> NON-REFUNDABLE PERMITtivww.s' ov.or /ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> y <br /> JOB ADDRESS �J0 1 l51CITY/ZIP <br /> CROSS STREET �t/� APN 4 PARCEL SIZE LAND USE APPLICATION# <br /> OWNERNAME .7",tTy A[ PHONE oy,+ <br /> OWNER ADDRESS 'Cr�C\\f1C �'fra.fiPAf 'P IA�q CITY/STATE21P Tric[�_�e�Q?�O <br /> CONTRACTOR ; nY PHONE 46 <br /> CONTRACTOR ADDRESS '/ r[� ?;rPGY� CITY/STATE/ZIP <br /> SUBCONTRACTOR/CONSULTANT N j Di Alf ny;jj ltnc�51 U 1 PHONE <br /> �\SUBCONTRACTORICONSULTANT ADDRESS a,Kln �k �. CITY/STATEMP 64,ftjt <br /> LICENSE V/C-'57 0 C-61 0 D-09 D Other NUMBER jLq0ti EXPIRATION DATE <br /> + BILLING PARTY: D OWNER CONTRACTOR D SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING:0 General Mineral/Coliform Bacteria(4391)0 Dibromochloropropane(4392)0 Arsenic(4393) <br /> INTENDED USE D DOmestic/PrIvate D Irrigation/Agricultural D Industrial L Water Quality Monitoring 1215oil Sampling/Characterization <br /> D Public Water System <br /> II'different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK D New Well 0 Replacement Well D Well Alteration/Modification D Other <br /> D Monitoring Well(s) #of wells D Soil Boring(s) #of borings 911eotechnical of borings <br /> D Out-Of-Service Well D Out-Of-Service Well Renewal ❑Cross-Connection Repair PA Y� <br /> D New Pum D Pum Replacement 7 Pum Repair L Raise Well Casing �A,� <br /> WELL CONSTRUCTION n�,�•wwwr <br /> Drilling Method -<.d Rotary C Air Rotary Auger D Cable Tool C Push Point L Other V /�D <br /> Proposed Well Depth6—\n ft Excavation in diameter 7 Open Bottom D Gravel Pack/Gravel Size in diameter :FP O <br /> I Conductor Casing in diameter / Conductor Casing Depth ft I3 �oe(} <br /> Well Casing Diamete�� n Thickness/Gauge/ASTM Schad 7 Steel 7 Plastic U Stainless Steel D Other S /.7 <br /> Grout Seal Depth oft WITeat Cement(94 Ib bao-10 gal water) -1 Sand Cement sack mix17 gal,w �Q C.O <br /> jjV <br /> ❑Bentonite(20%solids) C Other r/ tij <br /> Grout Placement Method dumped C Free Fall D Other L Retardant/Accelerator(name) "�T r"k <br /> PEDESTAL Installed By D Driller D Pump Contractor 7 Other MFNT <br /> u Concrete Pedestal L Dimensions:Width ft Length ft Thick in L Christy Box L Stove Pipe <br /> PUMP I I Submersible I Turbine I 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 /> MINIMUM 48 H A �jpL�C TICE REQUIRED FOR IINNSffECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED v � TITLE 7\al'\1 \"���� DATE q <br /> iT 111.1 <br /> A M E N T U SOE CI L Y <br /> Application Accepted By Date C Area Employee ID# <br /> Grout Inspection By Date $PECIA ell Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE Sc Received Check#/ Amount Permit/ <br /> odes Info Cash emitted Date Service Request# Invoice# Well ID# <br /> EHD 4306 611112019 �S7gZ��Z WELL/PUMP PERMIT <br />