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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1068 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232(209)468-3420 <br /> NON-REFUNDABLE PERMIT www.sigov.org/ehd EXPIRES 1 YEAR FROM DATES ISSUED <br /> � <br /> JOB ADDRESS 5 � Q1A <br /> '5 11o41e0 Rd. _ CITY/Z.IP S }[)n .lQ QS�IJ r� <br /> CROSS STREETW ftk91- � —APN 089-2.20-AI I PARCEL SIZE.5 LAND USE APPLICATION# p <br /> OWNER NAME R1( f4� C 1A1, t[` PHONE l��I�/dfO�s r In <br /> OWNER ADDRESS 51��aIAIY►D JX-IIACITY/STATE/ZIP S40Ck.}-dr/ <br /> CONTRACTOR �.�1l A.Y.L.Lt�{A� � � PHONE Sli- fin <br /> CONTRACTOR ADDRESS %01„_-A Ibe . CITYISTATE/ZIPj%4,J-#Sb o CA <br /> SUBCONTRACTORICONSULTANT PHONE <br /> SUBCONTRACTORICONSULTANT ADDRESS _ CITY/STATE/ZIP �t <br /> LICENSE }[C-57 D C-GI III D-09 LI Other_ NUMBER (./SEXPIRATION DATE <br /> BILLING PARTY: ;IOWNER CONTRACTOR SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING:1 1 General Mineral/Coliform Bacteria(4391)11 Dibromochloropropane(4392)1:Arsenic(4393) <br /> INTENDED USE Domestic/Pdvale 0 Irrigation/Agricultural 11 Industrial D Water Quality Monitoring O Soil Sampling/Characterization <br /> . 0 Public Water System <br /> If different from Oanec Wale,System Name Contact Name or Phone Number <br /> TYPE OF WORK 11 New Well Replacement Well 0 Well Alleialion/Modification 0 Other <br /> 0 Monitoring Weil(s) #of wells 0 Soil Borings) a of borings 0 Geotechnical M or borings <br /> 0 Oul-Of-Service Well r3 Out-Of-Service Well Renewal O Cross-Connection Repair <br /> 0 New Pump 0 Pump Replacement 0 Pump Repair rJ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary 0 Air Rotary D Auger D Cable Tool 0 Push Point 0 Other <br /> Proposed Well Depth :3!50 1 .it Excavation It1Lt i in dlarneter 0 Open Bottom )(Gravel Pack/Gravel Size_in diameter <br /> D Conduct r Casing in dlameler / Conductor Casing Depth fl <br /> Well Casing Diamelet in Thickness/Gauge/ASTM Sched7.41`0 0 Steel -y<Plastic 0 Stainless Steel 0 Other <br /> Grout Seal Depth /d d It 0 Neal Cement(941b bag/5-10 gal water) rJ Send Cement sack mix/7 gal water <br /> ?(BenI Ile(20%solids) 0 Other <br /> Grout Placement Method umped n Free Fall D Other 0 Retardant I Accelerator(name) <br /> PEDESTAL Installed By LI Driller LIMP Contractor El Other _ <br /> Concrete Pedestal nDimensions:Width it Length fl Thick in 0 Christy Box 0 Stove Pipe <br /> fPUMP 0 Submersible Ll Turbine LI Other HP Pump Set_ it Standing Water Level fl <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 /> 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209))953-7697 <br /> SIGNED TITLE D(,tlMtr• DAl /'E —2 7-l <br /> E pAj T E T <br /> ,_---B-EPARTMENT USE ONLY <br /> Application Accepted By _ Dale Area mployee ID# �Y�- <br /> Grout Inspection By _ Dale SPECIAL Well Permit <br /> Pump Inspeclion By Dale Y. WAIVER Received <br /> Soil Boring Ins action By Dale Constr/ticI Well Depth_ It <br /> COMMENTSoi$7�..Q �./Ls�ySZV (,t "P <br /> PF SC Receive Check#/ Amount Date Permit/ Involve# Well ID# <br /> Codes In CpQ Remitted Service Re c nest# <br /> SR l �f <br /> _ -- p --- <br /> E1-1041-06 6111/2019 WELL/PUMP PERMIT <br />