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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.org1ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 1785 0 VOLn IN((�A t ceet CITY/ZIP ES CQ(1)3!:� /553) <br /> CROSS STREETYo !�:g Ltj� q APN 2a 5 2-5 o Vi PARCEL SIZE <br /> t 1 (' }� 16�5 LAND USE APPLICATION# A <br /> �- <br /> OWNER NAME r`COt1� A1f�Pri \� {\ �)d(;C\ _ ACr PHONE rMe, <br /> OWNER ADDRESS 152, of yQ5CMjU NX CITY/STATEQIP F—S1,_('A '5320 <br /> CONTRACTOR PH.ONE ��9I� <br /> .9 Lil. 45 L <br /> CONTRACTOR ADDRESS 2DOI rch�l(D rt R-(2111r,1wtP`�t� CITY/STATE/ZIP s1JOcKto � (�pl5abV <br /> SUBCONTRACTOR/CONSULTANT \1 61W—y(�I(1Aq PHONE <br /> t.,2n9.9�I-1]55 <br /> SUBCONTRACTOR/CONSULTANT ADDRESS 113 R(L6C(S�IE�3�' 11� CITY/STATE/LP�.�,Q(t !�1 9f,5 6,31 ^^ <br /> LICENSE 1.C-57 C-61 iJ D-09 -1 Other NUMBER �')ng n y EXPIRATION DATE 1�1 .�I).1-D2 1 <br /> BILLING PARTY: :.:OWNER /CONTRACTOR ❑ SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELLSAMPUNG::-General Mineral/Coliform Bacteria(4391)-Dibromochloropropane(4392)F,I Arsenic(4393) <br /> INTENDED USE ❑Domestic/Private Irrigation/Agricultural L: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 D Replacement Well D Well Alteration/Modification 7 Other <br /> D Monitoring Well(s) #of wells C:7 Soil Boring(s) #of borings C.I Geotechnical #of borings <br /> D Out-Of-Service Well ❑Out-Of-Service Well Renewal 3 Cross-Connection Repair <br /> ❑New Pump ❑Pump Replacement ❑Pump Repair D Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method V Mud Rotary ❑Air Rotary 4 Auger i_ Cable Tool ❑Push Point l Other <br /> Proposed Well Depth IS ft Excavation in diameter ❑Open Bottom of Gravel Pack/Gravel Size in diameter <br /> D Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Sched _7 Steel Plastic D Stainless Steel r Other <br /> Grout Seal Depth ft 4 Neat Cement(94 lb bag/5-10 gal water i Sand Cement sack mix/7 gal water <br /> ❑Bentonite(20%solids) D Other <br /> Grout Placement Method Pumped D Free Fall D Other D Retardant/Accelerator(name) <br /> PEDESTAL Installed By _Driller ❑Pump Contractor ❑ Other <br /> Concrete Pedestal❑Dimensions:Width ft Length ft Thick in C Christy Box C Stove Pipe <br /> PUMP Submersible-_Turbine ❑Other HP Pump Set ft Standing Water Level It <br /> 1 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 LICEI��S M�O �O <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WIT <br /> WORKERS COMPENSATION LAWS. 1 <br /> M I U 48 HQUR ADVAN E NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-769y�( �iQ Q�//N <1&1, <br /> SIGNED TITLE Vf0fe, DATE 0& <br /> 'y <br /> M'y <br /> all] <br /> PARTMENT USE N Y <br /> IF <br /> Application Accepted By DateWYN Area Employee ID1(YA <br /> Grout Inspection By Date PECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#/ Amount Da Permit/ Invoice# Well ID# <br /> Codes Info B Ca Remitted Service Re uest# <br /> I <br /> EHG 43-08 8/112019 C�, WELL/PUMP PERMIT <br />