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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 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 /> "A��r L; rn <br /> Joe ADDRESS x 1�, h�C: (�-e��� CITY/ZIP <br /> a <br /> CROSS STREET S NIA <br /> IA APN t y 'G SC: 2.3 PARCEL SIZE LAND USE APPLICATION# o <br /> m <br /> OWNER NAME -J_G��d CC �':YIC VY—L UlfY i),'J 0- (11c, C::j P,y PHONE L L;r t q'9 C,t <br /> OWNER ADDRESS 2.3tG4 L<1��"+Y/�) K(,;�C(\ CrrY/STATE/ZIP <br /> CONTRACTOR �' V\j PHONE Ci. <br /> -6� <br /> CONTRACTOR ADDRESS t� ckcy V't�� �� VL- CITY/STATE/ZIP <br /> 1P l-lG�� CA <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP q <br /> LICENSE iY C-57 ❑C-61 ❑D-09 ❑Other NUMBER %�;r1 Q`� EXPIRATION DATE 1,0 1 Z I 1 <br /> DOMESTIC WELL SAMPLING:❑General Mineral/Coliform Bacteria(4391)7 Dibromochloropropane(4392)r-Arsenic(4393) <br /> INTENDED USE n Domestic/Private ❑Irrigation/Agricultural n Industrial n Water Quality Monitoring Soil Sampling/Characterization <br /> Fl Public Water System <br /> If different from Owner Water System Name Contact Name or Phone Number <br /> TYPE OF WORK n New Well n Replacement Well n/Well Alteration/Modification n Other <br /> nMonitoringWell(s) #of wells IfySoilBoring(s) #of borings nGeotechnical #of borings <br /> n Out-Of-Service Well n Out-Of-Service Well Renewal n Cross-Connection Repair <br /> - New Pump n Pump Replacement ❑Pump Repair n Raise Well Casing <br /> WELL CONSTRUCTION � <br /> Drilling Method n Mud Rotary n Air Rotary ]/Auger ❑Cable Tool ri Push Point n Other <br /> Proposed Well DepthIt Excavation in diameter I Open Bottom n Gravel Pack/Gravel Size _in diameter <br /> n Conductor Casing _in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Schad ❑Steel F Plastic ❑Stainless Steel i`Other <br /> Grout Seal Depth !JC; it n Neat Cement(94 Ib bag/5-10 gal water) n Sand Cement sack mix/7 gal water <br /> r1 Bentonite(20%solids) n Other <br /> Grout Placement Method n Pumped ❑ Free Fall ❑Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By n Driller :;Pump Contractor ❑ Other <br /> F Concrete Pedestal ]Dimensions:Width ft Length It Thick in n Christy Box n Stove Pipe <br /> PUMP Submersible-Turbine ❑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 /> M h 48 HOU ADV NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-769f7 <br /> SIGNFd' TITLE t. �Y�G G"a- DATE � <br /> IT 1 101 <br /> E1� ® <br /> 0 2019 <br /> IN CptjN <br /> N <br /> ART,NENT <br /> A <br /> M E N T UZ E60 LY <br /> Application Accepted By a Area Employee ID#--/� <br /> Grout Inspection By Date 0 PECIA Well Permit <br /> Pump Inspection By Date I WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info as Remitted e ce R st# <br /> EHD 43-06 i ieed 4/14118 y� l �.,U/ (y WELL/PUMP PERMIT <br /> 1 •$1 C3�,- <br />