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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.sigov.org/ehd -t�EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 571 Int." CITY/ZIP 1 trG(�953 <br /> 7 D <br /> CROSS STREET APN 2-0')I jnX0 PARCEL SIZE LAND USE APPLICATION# o <br /> �� p Cr!S m <br /> OWNER NAME rrIr PHONE <br /> OWNER ADDRESSko J-m-& j< �yl� t y CITY/STATE/ZJP9i1 <br /> y�IN�V HA 9/ N <br /> CONTRACTOR IC ll�l A tPI.J PY T� 1 ` PHONEL}2s�9./9' / <br /> CONTRACTOR ADDRESS ') onl Ax�h-Rty---art oq j _Cu11 Fjj)0CITYJSTATE/ZJP StOCI�t.A l�1O' <br /> SUBCONTRACTOR/CONSULTANTV &W :Dfil� PHONE a o.9% 1755 <br /> SUBCONTRACTOR/CONSULTANT ADDRESS 4 W I a-C- ^hy4(-S� Dl, CITY/STATEIZJP�aA I C p,T�63Z <br /> LICENSE 6(C-57 rl C-61 D D-09 D Other NUMBER '7')—oq n q EXPIRATION DATE n4.3 o.2,olo <br /> BILLING PARTY: Li OWNER iCONTRACTOR D SUBCONTRACTORICONSULTANT <br /> DOMESTIC WELL SAMPLING:❑General Mineral/Coliform Bacteria(4391)J Dibromochloropropane(4392) Arsenic(4393) <br /> n!E D Domestic/Private ❑Irrigation/Agricultural ❑Industrial D Water Quality Monitoring il Soil Sampling/Characterization <br /> D Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK D New Well D Replacement Well D Well Alteration/Modification ❑Other J <br /> J MonitoringWell(s) #of wells ❑SoilBoring(s) #ofbodngs M Geotechnical tj floorings <br /> D Out-Of-Service Well ❑Out-Of-Service Well Renewal -1 Cross-Connection Repair <br /> ❑ New Pump D Pump Replacement ❑Pump Repair D Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method I Mud Rotary ❑Air Rotary J Auger D Cable Tool ❑Push Point . Other <br /> Proposed Well Depth S-30 ft Excavation in diameter ❑Open Bottom D Gravel Pack/Gravel Size in diameter <br /> -1 Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched D Steel D Plastic D Stainless Steel ❑Other <br /> Grout Seal Depth ft ff Neat Cement(94/b bag/5-10 gal water) i_i Sand Cement sack mix7 gal water <br /> J Bentonite(20%solids) D Other <br /> Grout Placement Method d Pumped C Free Fall D Other C Retardant/Accelerator(name) <br /> PEDESTAL Installed By D Driller D Pump Contractor C Other <br /> -1 Concrete Pedestal ODimensions:Width ft Length ft Thick in C Christy Box D Stove Pipe <br /> PUMP ❑Submersible[--Turbine D 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 HOUR ADV NCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)9(�53-7697 <br /> SIGNED ^ TITLE YJ 9i��kf Dr0[C SSr aIIQI DATE <br /> SAM <br /> 8VI "j <br /> -74 <br /> PA TMENT U E O LY <br /> Application Accepted By Date Area Employee ID# �1� <br /> Grout Inspection By Date L SPECIA Well Permit <br /> Pump Inspection By Date C WAIVER Received <br /> Soil Boring Inspection By N(A 11, Date ' r ! Constructed Well Depth ft <br /> COMMENTS 7 .S <br /> PE SC Received Check#I Amount Permit) <br /> Codes Info B Cash Remitted Date ervice Request# Invoice# Well ID# <br /> r <br /> EHD 43-06 6/112019 WELL/PUMP PERMIT <br />