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WELL/PUMP PERMIT 0)661&1EYED <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 11868 EAST HAZELTON AVENUE-STOCKTON CA 995205-6232 (209)468-3420 <br /> NON-REFUNDABLE PERMIT www.sigov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS cirAl CITY/ZIP � <br /> CROSS STREET eA P N .� O� o <br /> (� /► ^,,� \f RCELL SIZE�I LAND USE APPLICATION# <br /> OWNER NAME �Iu�. 1.�.J l�U_% NA tch 8� L Y Iror ja M PHONE 2D { - -! ' U D Cn <br /> u! <br /> OWNER ADDRESS ��}O [/�D�IL. "N, CITY/STATE/ZIP �_Ckkn� CAA �'i5/�js <br /> CONTRACTOR U _t0Atr S ` <br /> PHONE �/1:209— —_� ID D <br /> CONTRACTOR ADDRESS L O CITY/STATE/ZIP C 2� <br /> SUBCONTRACTOR/CONSULTANT PHONE <br /> SUBCONTRACTOR/CONSULTANT ADDRESS CITY/STATE/ZIP <br /> LICENSE XC-57 ❑ C-61 ❑ D-09 ❑ Other NUMBER—WIEXPIRATION DATE It. 21 I <br /> BILLING PART/Y•: ❑OWNER ❑CONTRACTOR ❑ SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING:❑General Mineral/Coliform Bacteria(4391)❑ Dibromochloropropane(4392)❑Arsenic(4393) <br /> INTENDED USE )CDomestic/Private ❑ Irrigation/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 /> ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings ❑ Geotechnical #of borings <br /> ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> ❑ New Pume )(Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method ❑ Mud Rotary ❑ Air Rotary ❑ Auger D Cable Tool ❑ Push Point ❑ Other <br /> Proposed Well Depth ft Excavation 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 D Steel ❑ Plastic ❑ Stainless Steel ❑ Other <br /> Grout Seal Depth ft ❑ Neat Cement(94 lb bag/5-10 gal water) ❑ Sand Cement sack mix/7 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 jit 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 <br /> JM 48 H R ADV CE NOTICE REQUIRED FO INSPECTIONS - PLEASE CALL(209) 953rrd�-7697 <br /> SIGNED TITLE DATE <br /> SO 14 <br /> T <br /> ED <br /> 019 <br /> el <br /> J A UI J COUNTY <br /> N 1R TAL <br /> MENT <br /> 1 ,4- 777 <br /> EP RTMENT tjSE PNLY <br /> &1jjC <br /> Application Accepted By — Date Area Employee ID#� <br /> Grout Inspection By c Date EI SPECIAL Well Permit <br /> s <br /> Pump Inspection By hr '(�r1Q CSGt("krn Date /1Ct ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#/ Amount Permit/ <br /> Co es Info B Cash R mitted Date Service Re uest# Invoice# Well ID# <br /> EHD43-06 6/11/2019 WELL/PUMP PERMIT <br />