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`• A/V t✓ts ►2 <br /> WELL/PUMP PERMIT <br /> SAN JOAQUIN 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 /> (� to <br /> JOB ADDRESS _ I'S C� \ S . HGvIL_ CITY/ZIP LAAyX � J m <br /> D <br /> CROSS STREET W ��lv�;, �2c� APN GIb` It - 02 1 PARCEL SIZE LAND USE APPLICATION# <br /> OWNER NAME r' ( L0e Vel/ U PHONE /J y <br /> OWNER ADDRESS �( J 6ti (��f�Q_ CITY/STATE/ZIP se <br /> CONTRACTOR 6 PHONE f1 (C,1- 3l C t <br /> CONTRACTOR ADDRESS Kut 1vS\ `, ltil CITY/STATE/ZIP L C� ( � 4 2'l,C7 <br /> SUBCONTRACTOR/CONSULTANT S w. o n C-' C> PHONE Cas b .a <br /> SUBCONTRACTOR/CONSULTANT ADDRESS &,— ct 4w CITY/STATE/ZIP w li Ca, <br /> LICENSE --C-57 _ C-61 L D-09 J Other NUMBER (.c(,'1 0o y EXPIRATION DATE S 31 2aZ\ <br /> BILLING PARTY: -OWNER ONTRACTOR - SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391)1 Dibromochloropropane(4392) - Arsenic(4393) <br /> INTENDED USE _ Domestic/Private L Irrigation/Agricultural Industrial - Water Quality Monitoring A 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 X Geotechnical Z #of borings <br /> Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair <br /> New Pump Pump Replacement Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method X Mud Rotary _ Air Rotary 2K Auger Cable Tool Push Point Other <br /> Proposed Well Depth 15'-S ft Excavation c. in diameter Open Bottom a Gravel Pack/Gravel Size in diameter <br /> ! Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched i i Steel I 1 Plastic n Stainless Steel Other <br /> Grout Seal Depth ft 6 Neat Cement(94 lb bag/5-10 gal water) J Sand Cement sack mix/7 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method L Pumped Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By i Driller IPump Contractor Other <br /> Concrete Pedestal Dimensions:Width ft Length ft Thick in - Christy Box - 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 /> MINIMUM 48 OU DVANCE NOTICE REQUIRED FOR INSPECTIONS -PLEASE CALL (209) 953-7697 <br /> SIGNED c TITLE r{l A 6C.10$ { 5� DATE Cl 17' PfUlel <br /> V`. <br /> CANjjo� <br /> ti <br /> Q INC <br /> NV R 4%3 ME T <br /> PARTMENT USE ONLY <br /> Application Accepted By Date 7 Area G w ployee ID# <br /> Grout Inspection By Date C ECIAL Well Permit <br /> Pump Inspection By A Date ,�l I WAIVER Received <br /> Soil Boring Inspection By Date l Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info95h Remitte Service Request# <br /> w e CQ a- <br /> EHD 43-06 6/11/2019 WELL/PUMP PERMIT <br />