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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�PE�RMIT"� www.sjgov.org/ehd �E_XXPPIIR/E�S 1 YEAR FROM/D�A�TE ISSUED <br /> JOB AD A* -JL•- MMMM�� _ cr'.PtAfty-IA ' 61S .TJT. <br /> CR OR , V�V'`C,�/J{� _�APN`t��{j/�0-�%Q0,-:b1 PARCEL SIZE 33 LAID USE APPLICATION# <br /> OWNER NAME rr`1^`- [���`�e,��r�. <br /> 06 Left __.. /PPHHONNEE,A ./.� /j.. . <br /> fW <br /> OWNERADDRESS 1 T ��•wNoslot-Am �f'j CT'/sTATE/ZIPMr11R.n�aA,1lra''C rtll;'3x331_ <br /> CONTRACTOR C ALAr.r.*0W�Y)�.�/�"r'�'^(/Okla r.�yZ • PHONE(4VNV 1ACtW �,'A{r�_AO4 <br /> CONTRACTORADDRE99 jh0 CaV",YCIJw}���S�CJiTT ��yv�4�4._ff; Ux�6[���CII111STTAATE21P /�I_ �{f�A I <br /> SUBCONTRACTOR/CONSULTANTgI%lLf .S`.�y]l'�{�7 &V;6%A9IY.-\�y[>�- $E*-'P C0.% q��PHHONE LOAg 7l-lil/,���.�J� <br /> SUBCONTRACTOR/CONSULTANTADDRESS 3 `V% fay��+ID •-r• Crr,/s.E/ZIVAtVr ]1 P&` QQ <br /> LICENSE X C-57 0 C-61 0 D-09 0 Other NLIMBER96422.4 _ EXPIRATION DATE 31 <br /> BILLING PARTY: C OWNER CONTRACTOR O SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLM:D General Mineral/Coliform Bacteria(4391)D Dibromochloropropane(4392)❑Amenic(4393) <br /> INTENDED USE O Domestic/Private ❑Inigetion/Agdcultural ❑Industrial ❑Water Quality Monitoring Soil Sampling/Characterizabon Irn <br /> [)Public Water System _ <br /> If Oifferenlfrom Owner mawsystem Nemo Conlad Name or Phone Number <br /> TYPE OF WORK 0 New Well D Replacement Well n Well Alterabon/Modification ❑Other <br /> ❑Monitoring Well(s) #ofwells XSoil Boring(s) xef b°ngs XGeolechnical xdponnga <br /> D Out-Of-Servioe Well ❑Out-(X Servioe Well Renewal ❑Cross-Connection Repair <br /> ❑New Pump 0 Pump Replacement ❑Pump Repair ❑Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method ❑Mud Rotary Cl Alr Rotary 7Auger ❑Cable Tool ❑Push Point ❑ Other <br /> Proposed Well Depth Cpf 0" ft Excavation 4�V in diameter D Open Bottom ❑Gravel Pack/Gravel Size in diameter <br /> D Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_in Thickn auge/ASTM Sched ❑Steel [)Plastic 0 Stainless Steel ❑Other_ <br /> Grout Seal Dapth _ ft A Neal Cement(94 Ib bag15-10 gal water) ❑Send Cement_ _ sack mod?gel water <br /> D Bentonite(20%solids) ❑Other <br /> Grout Placement Method)CIPUmped J10 Free Fell D Other D Retardant/Accelerator(name) �y <br /> Installed By ❑Driller D Pump Contractor ❑ Other <br /> 0 Concrete Pedestal[)Dimensions:Width R Length___it Thickin ❑Christy Box ❑Stove Pipe <br /> ❑Submersible[)Turbine D Other HP Pump Set it Standing Water Level R <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 /> I UM 48OU A GEN F(JUIRED FQ8INSPECTIONS-PLEASeEE/VCALL(20151 <br /> DASIGNED TRLEnVF/\ <br /> SEP �® <br /> o ?419 <br /> FNS qQU/ <br /> yt4CTy�OpM�OUN)7- <br /> FNT <br /> ER RTMENT U E Ot/SLY <br /> Application Accepted By _ _ Dete C !� � Anse# Yee ID# <br /> Grout Inspection By Dete ❑ SPECIAL Well Permit <br /> Pump Inspection By Date�//1�yy//�'')) //1J //--���� [IWAIVER Received <br /> Soil Boring Inspecflon By _ ate (( <br /> —11rL_J Constructed Well Depth _ ry <br /> COMMENTS <br /> PE SC Received Cheek#/ AmountDeft PermiU Invoice# Well ION <br /> Codas Info Cas Remitted Service Re uestN <br /> W F00401 a <br /> FHD4306 8/1102019 WELLIPUMPPERMrr <br /> �G�7/370 <br />