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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232 (209)4683420 <br /> • NON-REFUNDABLE PERMIT www.sjgov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> G j 41 <br /> JOB ADDRESS / 5 CC p CITY/ZIP �.SC/•//Q�( /Jy.Z _8 m <br /> AW ep�ArR p D <br /> CROSS STREET <br /> APN�Z�'��O -020 PARCEL SIZE (.3 A 5 AP ICAT N# <br /> m <br /> OWNER NAME / <br /> OWNER ADDRESS /rs • /y— CITY/STATE/ZIP �SCN/0 n C/'4- • J �n <br /> CONTRACTOR J 1 .i- PHONE7- <br /> 1 <br /> CONTRACTOR ADDRESS ?042 /�. / C7 c. CITY/STATE/ZIP�tR qc. `C/'f. �J��.O <br /> SUBCONTRACTOR/CONSULTANT PHONE <br /> SUBCONTRACTOR/CONSULTANT ADDRESS CITY/STATEIZIP <br /> LICENSE 1;-e-57 r C-61 n D-09 O/they NUMBER W Y� EXPIRATION DATE J 3 _ ;2 <br /> BILLING PARTY: L OWNER NTRACTOR SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING:0 General Mineral/Coliform Bacteria(4391)❑Dibromochloropropane(4392)0 Arsenic(4393) <br /> INTENDED USE "omestic/Private D Irrigation/Agricultural C Industrial 0 Water Quality Monitoring 7 Soil Sampling/Characterization <br /> 7 Public Water System <br /> If different from Owner. Water System Name Contact Name or Phone Number <br /> TYPE OF WORK NCew Well 'Replacement Well I Well Alteration/Modification I Other <br /> MonitoringWell(s) #Of wells r- SoilBoring(s) #ofborings Geotechnical #of borings <br /> Out-Of-Service Well L Out-Of-Service Well Renewal u Cross-Connection Repair <br /> New Pum .3 Pump Replacement ❑Pump Repair D Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method""ud Rotary 0 Air Rotary 0 Auger ❑Fable Tool 7 Push Point ❑ Other <br /> Proposed Well Depth S�d ft Excavation in diameter L Open Bottom &-Gravel Pack/Gravel Size_ in diameter <br /> 7 Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter jr), 'ckness/Gauge/ASTM Schad ZI 7 C Steel O.Wastic Stainless Steel G Other <br /> Grout Seal Depth "`)T0 Neat Cement(941b bag/5-10 gal water) L Sand Cement sack mix17 gal water <br /> A;-Bentonite(20%solids) n Other <br /> Grout Placement Method a-Anmped -1 Free Fall -1 Other 7 Retardant/Accelerator(name) <br /> PEDESTAL Installed By 7 Driller JPWTmp Contractor D Other <br /> 7 Concrete Pedestal[]Dimensions:Width ft Length ft Thick in D Christy Box 0 Stove Pipe <br /> PUMP a ubmersibleD Turbine 0 Other HPC 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. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AN ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS C PENSATION LAWS. <br /> M MU O R A ANCE NOTICE REQUIRED FOR INSPECTION -PLFASE CALL(209)53-7697 Q <br /> SIGNED TITLE. �C.e)AV & !'.S -- DATE 2 Y- <br /> PAYMENT <br /> RECEIVE® <br /> c <br /> -"[-P 2 4 2019 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> PA MENT U E DAILY <br /> Application Accepted By ate 91 Area Employee ID#A0 <br /> Grout Inspection By Date ❑ PECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> ,n <br /> Soil Boring Insetion By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#/ Amount Permit/ <br /> Codes Info ByZ Cash Remitled ate Service Reg eat# Invoice# Well ID# <br /> WP004b t a <br /> ,o <br /> EHD43-06 6/11/2019 WELL/PUMP PERMIT <br />