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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.s ov.oC /ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 6103/3 f <<�� �- <br /> CITYIZIP m <br /> D <br /> CROSS STREET _A 6 71 Z.Z-/J zj O PARCEL SIZE LAND USE APPLICATION# o <br /> m <br /> OWNER NAME PHONEao� <br /> OWNER ADDRESS ,� CITY/STATE/ZIPICJij��lT� <br /> CONTRACTOR S PHONE <br /> �//�%T <br /> CONTRACTOR ADDRESS dD Arxd CITY/STATE/ZIP .(A '95a ,14_ <br /> SUBCONTRACTOR/CONSULTANT _ A/ A PHONE j> <br /> SUBCONTRACTOR/CONSULTANT ADDRESS CITY/STAT <br /> E/ZIP <br /> LICENSE ❑ C-57 )(C-61 11 D-09 U Other NUMBER#6W_U-- EXPIRATIONDATE <br /> BILLING PARTY: I GONER I I CONTRACTOR SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391)i, Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE omestic/Private ❑ Irrigation/Agricultural n Industrial r_l Water Quality Monitoring ❑ Soil Sampling/Characterization <br /> ❑ Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK ❑ New Well ❑ Replacement Well ❑Well Alteration/Modification ❑ Other <br /> ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings ❑ Geotechnical r <br /> ❑ Out-Of-SeryW II 1] Out-Of-Service Well Renewal ❑ Cross-Connection Repair � 1��� <br /> ice <br /> ❑ New Pum 'Pump Replacement ❑ Pump Repair ❑ Raise Well Casing �r <br /> WELL CONSTRUCTION <br /> Drilling Method ❑ Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other SAN JO_AAQI11�,„_ �Tv <br /> Proposed Well Depth Conductor Casingft Excan aiiion / Conductor diameter <br /> Casing DD Open Bottom 11 Gravel Pack/Gravel HI rq�DONM4tyyT7 L 1leter <br /> th -ft <br /> Well Casing Diameter_ in Thickness/Gauge/ASTM Sched ❑ Steel 11 Plastic ❑ Stainless Steel U Other <br /> Grout Seal Depth_ ft ❑ Neat Cement(94 Ib Gag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water <br /> rl Bentonite(20%solids) ❑ Other <br /> Grout Placement Method rl Pumped ❑ Free Fall ❑ Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other <br /> ❑ Concrete Pedestal❑Dimensions:Width ft Length ft Thick in U Christy Box ❑ Stove Pipe <br /> PUMP yiSubmersibleo Turbine ❑ Other HP Pump Set ft Standing Water Level . ft <br /> I I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAI' 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 /> 7=�`NOok�IaVANCE NOTICE REQUIRED FOR <br /> /INSPECTIONS-PLEASE CALL(209) 953-7697 <br /> / <br /> SIGNED TITLE //�j/� DATE 141;;;- <br /> DEPARTMENT USE ONLY <br /> Application Accepted By if Date Area Employee ID#_V� <br /> IF <br /> Grout Inspection By Date PECIAL Wel) Permit <br /> Pump Inspection By LtLA1 Date�110, _ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received he Amount Date Permit/ Invoice# Well ID# <br /> Codes Into B Cas Remitted Service Re uest# <br /> 'aLalyy W604021 <br /> EHD 43-06 6/11/2019 WELL/PUMP PERMIT <br />