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WELL/PUMP PERMIT <br /> SAN JG4"'4UIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232 (209)468-3420 <br /> NON-REFUNDABLE PERMIT www.sjgov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> 1 l I 11 LA <br /> JOB ADDRESS { `t�J N 1<�Vns I G(r, CITY/ZIP _LA 1 m <br /> r <br /> CROSS STREET 1� �]. I ICA r`()-i'� b V) APN UO-;T PARCEL SIZE 1 LAND USE APPLICATION# A <br /> OWNER NAME 4_v'0; l im]'F L�_�lGt 1� w+) / 1 PHONE ?_12 { 1 '7 2--L3 y <br /> OWNER ADDRESS f3epJ (i Y! C J "/ r\ CITY/STATE/ZIP e'-& ;15-Z_gO <br /> CONTRACTOR le?-fi C1 r�J� �P i'SU`�C>VI�S � I\I��Iy lbAzy,o J-, r PHONE 1��� ��C7 7— <br /> CONTRACTOR ADDRESS 102 Z�- ('I( I 0(j,� CITY/STATE/ZIP L04, <br /> SUBCONTRACTOR/CONSULTANT oLYA&, PHONE <br /> SUBCONTRACTOR/CONSULTANT ADDRESS CITY/STATE/ZIP y <br /> LICENSE A'C-57 C-61 _i D-09 i Other NUMBER 6G I Ud H EXPIRATION DATE S"31 L() 2 <br /> BILLING PARTY: _OWNER CONTRACTOR -' SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391)C Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE - Domestic/Private L Irrigation/Agricultural - Industrial - Water Quality Monitoring XSoil 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 a Replacement Well L Well Alteration/Modification ❑ Other <br /> Monitoring Well(s) #of wells ( Soil Borings) #of borings r Geotechnical #of borings <br /> Out-Of-Service Well Out-Of-Service Well ReOerwal Cross-Connection Repair <br /> New Pump Pump Replacement Pump Repair I I Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method - Mud Rotary Air Rotary KAuger Cable Tool - Push Point Other <br /> Proposed Well Depth10-50ft Excavation in diameter = Open Bottom G Gravel Pack/Gravel Size in diameter <br /> 1 Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched Steel I i Plastic Stainless Steel Other <br /> Grout Seal Depth ft Neat Cement(94 lb bag/5-10 gal water) r Sand Cement sack mix/7 gal water <br /> Bentonite(20%solids) _I Other <br /> Grout Placement Method - Pumped Free Fall = Other L Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller Pump Contractor j /fit r <br /> - Concrete Pedestal Dimensions:Width Thick in - Christy Box - Stove Pipe <br /> PUMP - Submersible_ Turbine - Other 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 /> MI IMUM 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS -PLEASE CALL (209) 953-7)697 <br /> SIGNED TITLE O ' , DATE 9 I6/ 20 )9 <br /> PA <br /> FST <br /> —4:09 <br /> EO <br /> F Q , <br /> 419 <br /> C y M TY <br /> MHT <br /> D RTMENTE LY C <br /> Application Accepted By Date U �O Area ( Employee ID# J✓�� <br /> Grout Inspection By Date [I PECIAL Well Permit <br /> Pump Inspection By so F Date F] WAIVER Received <br /> Soil Boring Inspection By Date 0202 Constructed Well Depth ft <br /> Aki <br /> COMMENTS S 07 <br /> PE SC Received ec Amount Permit/Codes Info B sh Remitted Date ervice Request# Invoice# Well ID# <br /> EHD 43-06 6/11/2019 WELL/PUMP PERMIT <br />