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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-6252(209)468-3420 <br /> NON-REFUNDABLE PERMIT - www.sigov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS ) 1 <br /> p O 1-7 �j N_ <br /> Ct If-, � CITyIZIP�rt�r N 7 B V <br /> CROSS STREET /UY/ // APN 2.LD-U 7 !7!I PARCEL SIZE bd o LAND USE APPLICATION# <br /> OWNER NAME D dkv`e ��e r S►'+'�� PHONE <br /> OWNER ADDRESS I�12 91 , (712((A L 1(`' CITY/STATE/ZIP /�/� <br /> -/Y aK, e-Cf <br /> CONTRACTOR f6.dSe11j I' ')r 1 1 I)K( Thir.. PHONE S'G.Z- <br /> CONTRACTOR ADDRESS I fol A I b e cs 'lc� CITYISTATE/ZIP MAJ4'[4(.1 r 4 <br /> SUBCONTRACTOR/CONSULTANT PHONE <br /> SUBCONTRACTOR/CONSULTANT ADDRESS CITY/STATE/ZIP / <br /> LICENSE )7 C-57 0 C-61 0 D-09 ❑Othef NUMBER 1G+ EXPIRATION DATE LI-3 d-Z <br /> BILLING PARTY: \<OWNER D CONTRACTOR t SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING:0 General Mineral/Coliform Bacteria(4391)❑Dibromochloropropane(4392)U Arsenic(4393) <br /> INTEN(1ED USE DomesticlPrivate 0 Irrigation/Agricultural 0 Industrial 0 Water Quality Monitoring O Sol[Sampling/Characterization <br /> 0 Public Water System <br /> It different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK ew well 0 Replacement Well ❑Well Alteration/Modification 0 Other <br /> 0 Monitoring Well(s) #of wells 0 Soil Boring(s) x or bo ripe 0 Geotechnical x or bo riga <br /> 0 Out-Of-Service Well 0 Out-Of-Service Well Renewal D Cross-Connectlon Repair <br /> ❑New Pump 0 Pump Replacement 0 Pump Repair D Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method'KMud Rotary 0 Air Rotary 0 Auger 0 Cable Tool 0 Push Point ❑ Other <br /> Proposed Well Depth :3N Excavation f�1 in diameter D Open Bottom IAGravel Pack/Gravel Size Tneo in diameter <br /> 0 Conductor Casing In diameter / Conductor Casing Depth ft <br /> Well Casing Dlameter,�_in Thickness/Gauge/ASTM Sched 7.jy�- 0 Steellastic 0 Stainless Steel ❑Other <br /> Grout Seal Depth?t%y it 0 Neat Cement(94 Ib bag/610 gal water) Mand Cement sack mix/7 gal water <br /> X8entonite(20%solids) 0 Other <br /> Grout Placement Method Vumped 0 Free Fall ❑Other 0 Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑Driller mp Contractor 0 Other <br /> D Concrete Pedestal❑Dime Ions:Width It Length ft Thick In ❑Christy Box D Stove Plpe <br /> PUMP D Submerslble0 Turbine 0 Other HP Pump Sel It 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 /> MI48H R ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED �� TITLE a (y,71npO­ DATE <br /> JMEN <br /> I; A UI N E T L <br /> P RTMENT U E ONLY v <br /> Application Accepted By Date Area Employee ID# <br /> Grout Inspection By <br /> Date (I PECIALWell Permit l <br /> Pump Inspection By Date LI WAIVER Received <br /> Soil Boring Ins ection By Date�� Co/r��t]�u fed Well Depth ft <br /> COMMENTS ���i1/�il/ �/��5 4/�f�6 ��" '^" <br /> PE SC Received Check#/ AmountDete PermlU Invoice# Well ID# <br /> Code Info B Cash emitted Service Re Uest# <br /> I o <br /> OWd <br /> Q `d <br /> WELL/PUMP PERMIT <br /> EHD 43-06 6/112018 <br />