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1 <br /> WELUPUMP 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 EXPIRES 1 YEAR FROM1 .DATE ISSUED <br /> JOB AD ESS pve IJ+'moi CITY/ZIP'''� j m <br /> CROSS STREET APN _PARCEL SIZE LANDUSE,APPLICATION# o <br /> nn7�6c5 <br /> OWNER NAME IE �•� /`�._� \ (_ n• �/'._..,,.1�.Nt'l IQ/_f./ C� PHONE r ' �, �2ll� N <br /> OWNERADDRESS 1) Fl �,.� :77u/ /0 -3Zs E tolk S CITY/STATE21P Cn,. A ez <br /> _ <br /> CONTRACTOR _ tt ry PHONE DCII 2� <br /> 'rl� — <br /> CONTRACTOR ADDRESS ,V(�. Nati tok !e6 CITY/STATE/ZIP <br /> SUBCONTRACTOR/CONSULTANT r Y'T*PS> lny;%,A d PHONE 6 <br /> SUBCONTRACTORICONSULTANT ADDRESS Q5 �wR & CI Y/STATE21P GiYi'1 n P� <br /> LICENSE V67 D C-61 0 D-09 _0 Other NUMBER 1 EXPIRATION DATE�L� <br /> BILLING PARTY: 0 OWNER Va CONTRACTOR ❑SUBCONTRACTOR/CONSULTANT 1 <br /> DOMESTIC WELL SAMPLING:D General Mineral/Coliform Bacteria(4391)0 Dibromochloropropane(4392)0 Arsenic(4393) <br /> INTENDED USE 0 Domestic/Private D Irrigation/Agricultural 0 Industrial 0 Water Quality Monitoring oil 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 D Other <br /> 0 Monitoring Well(s) #ofwells 0 Soil Boring(s) #ofbodngs tl�<-eotechnical #of borings <br /> 0 Out-Of-Service Well D Out-Of-Service Well Renewal 0 Cross-Connection Repair <br /> 0 New Pump D Pump Replacement 7 Pump Repair C Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method D Mud Rotary C Air Rotary 7 Auger D Cable Tool "K..h Point C Other <br /> Proposed Well Depth It Excavation in diameter 7 Open Bottom D Gravel Pack/Gravel Siza in diameter <br /> I I Condu or Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Schad 7 Steel 7 Plastic 0 Stainless Steel 0 Other <br /> Grout Seal Depth 9W ft 'IwK—eat Cement(94 Ib bag/5-10 gal water) -1 Sand Cement sack mW7 gal water <br /> D Bentonite(20%solids) C Other <br /> Grout Placement MethodWfumped C Free Fall AOther C Retardant/Accelerator(name) <br /> PEDESTAL Installed By 0 Driller D Pump Contractor 7 Other <br /> U Concrete Pedestal UDlmensions:Width It Length ft Thick in L Christy Box L Stove Pipe <br /> PUMP I I Submersible I Turbine i 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 AA <br /> WORKERS COMPENSATION LAWS. L <br /> MINI MM 48 HOUR NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 RAJI/�{9�pAp�� <br /> SIGNEDi TITLE if4'1OtItRPI_ DATE c{,��'■ v <br /> 6 ,9 <br /> � IV <br /> q c <br /> H F��'/y7Y <br /> MFNT <br /> PA TMENT U E NLY <br /> Application Accepted By tf Area Employee ID# <br /> Grout Inspection By Date ❑ SPECIAL ell 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 Permit/ods Info Cas itte Date S •ce Request <br /> # Invoice# Well ID# <br /> EHD43-06 6/11/2019 m/� ��� WELL/PUMP PERMIT <br />