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R ' <br /> 46 <br /> ,v\0 ' 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 vvwvv.sjgov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> 1 1 N <br /> JOB ADDRESS CITYIZIP <br /> ` a <br /> CROSS STREET� M_i` t� 8 ApPN ) PARCEL SIZE ,,LAND USE APPLICATION# A <br /> OWNER NAME ,/ v PHONE <br /> OWNER ADDRESS, <)- f) 111 -� / d ��Si�ycyy!Com`9ITYISTATETZIP�Cn <br /> I o S3S <br /> CONTRACTOR V1/f�. n) _.. PHONE- )A <br /> CONTRACTOR ADDRESS�Ov_ �f «��I�pGY nlC CITY/STATE/Zip< -- ,- r..n /'rN 1 91rO 6 <br /> SUBCONTRACTORICONSULTANT� � �Y��\.�G PHONE f6 <br /> pp fir� '/ <br /> SUBCONTRACTOWCONSULTANT ADDRESS �T o flw0 CITYISTATE/ZIP M crrL nP� I Z t -' 9(1 tri <br /> LICENSE V 57 0 C-61 0 D-09 .❑,Other NUMBER EXPIRATION DATE y _ <br /> BILLING PARTY: 0 OWNER Va�.ONTRACTOR ❑SUBCONTRACTORICONSULTANT <br /> DOMESTIC WELL SAMPLING:❑General Mineral/Coliform Bacteria(4391)❑Dibromochloropropane(4392)0 Arsenic(4393) <br /> INTENDED USE ❑DOmesticlPrIvate 0 Irrigation/Agricultural 0 Industrial D Water Quality Monitoring oil 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 D Replacement Well D Well Alteration/Mori fication D Other <br /> D Monitoring Well(s) #of wells 0 Soil Borings) #of borings tl, eotechnical #of borings <br /> D Out-Of-Service Well D Out-Of-Service Well Renewal D Cross-Connection Repair <br /> 0 New Pump 0 Pump Replacement 7 Pump Repair C Raise Well Casing <br /> WELL CONSTRUCTION � <br /> Drilling Method 0 Mud Rotary C Air Rotary 7 ll <br /> Auger 0 Cable Tool ' Push Point C Other <br /> Proposed Well Depth ft Excavation in diameter 7 Open Bottom 0 Gravel Pack/Gravel Size in diameter <br /> I I Co idu or Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_11 Thickness/Gauge/ASTM Schad 7 Steel 0 Plastic D Stainless Steel 0 Other <br /> Grout Seal Depth Q_ft lWee.t Cement(94 Ib bag/5-10 gal water) -1 Sand Cement sack m1x17 gal water <br /> 0 Bentonite(20%solids) C Other <br /> Grout Placement Method>i0fumped C Free Fall D Other C Retardant/Accelerator(name) <br /> PEDESTAL Installed By 0 Driller 0 Pump Contractor 3 Other <br /> U Concrete Pedestal UDimensions:Width ft 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. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MINI M 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 10 <br /> SIGNED TITLE��ln' ,�'t�tf/49s>_ DATE <br /> Uy p �� <br /> �AIRTMENT UE ONLY <br /> Application Accepted By VDate tltz Area Employee <br /> Grout Inspection By Date ❑ SPECIAL ell Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection By Date 1155 Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#/ Amount Date Permit/asInvoice# Well ID# <br /> Codes Info Ca h Remitted Service Re rrt# <br /> EHD 43-06 611 1)2019 � �/� // WELL(PUMP PERMIT <br />