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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.sjgov.org/ehd /,`EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS on CITY/ZIP fw I r/a <br /> CROSS STREET APNlqq Orn IQ, PARCELSIZE LAND USE APPLICATION# z <br /> ///111 <br /> OWNER NAME ,/G�.lt � E /�G1 iib'\ / Yf�[.� C PHONE Ao-a I y <br /> OWNER ADDRESS' (1 CIT//STATE21P Cin.. _ GI.I rIw <br /> CONTRACTOR 1.l 1 n,A k.,I.I_ - A PHONE50� 4 �T I rte_ <br /> CONTRACTOR ADDRESS�C 6�11�NI^ttY I.`OTN _ eA CIN/STATE/ZIP <br /> SUBCONTRACTORICONSULTANT(;tam r)Y;%6 PHONE r D <br /> SUBCONTRACTOR/CONSULTANT ADDRESS��i���AWg &� CITYISTATE21P MQty1nPz <br /> LICENSE V47 ❑C-61 0 D-09 ❑Other NUMBER i 0 W I 1 ,61, EXPIRATION DATE <br /> BILLING PARTY: D OWNER \Z CONTRACTOR C SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING:❑General Mineral/Coliform Bacteria(4391)❑Dibromochloropropane(4392)❑Arsenic(4393) <br /> INTENDED USE D DomesticlPrivate D Irrigation/Agricultural D Industrial ❑Water Quality Monitoring Aff0toll 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 ❑Replacement Well D Well Alteration/Modification D Other <br /> 0 Monitoring Well(s) #ofwells D Soil Boring(s) #of borings ,eotechnical aofbodngs <br /> D Out-Of-Service Well ❑Out-Of-Service Well Renewal D Cross-Connection Repair <br /> D New Pump D Pump Replacement 7 Pump Repair C Raise Well Casing <br /> WELL CONSTRUCTION � " <br /> Drilling Method -3 Mud Rotary C Air Rotary 7 Auger 11 Cable Tool T/Push Point C Other , <br /> Proposed Well Depthft Excavation in diameter C Open Bottom ❑Gravel Pack/Gravel Size in diameter <br /> i Condu or Casing in diameter / Conductor Casing Depth ft <br /> NQWell Casing Diameter�in Thickness/Gauge/ASTM Schad !I Steel 7 Plastic 11 Stainless Steel 11 Other li <br /> Grout Seal Depth f ft �at Cement(94 lb bag/5-10 gal water) Sand Cement sack mix/7 gal w�e Y 6 <br /> C Bentonite(20°h solids) C Other ✓�q <br /> Grout Placement MethodWfumped C Free Fall Other C Retardant!Accelerator(name) j QU//� <br /> PEDESTAL Installed By D Driller D Pump Contractor 7 OtherAN 40Z 4- <br /> u Concrete Pedestal LDimensions:Width ft Length ft Thick in L Christy Box L Stove Pipe /YD Fp�TM 4 <br /> PUMP i i Submersible I Turbine I Other HP Pump Set It Standing Water Level ft GHJ <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 /> MINIMIAM 4Jf8'��H�O.UUR—ADVANCE NOTICE REQUIRED FOR INSPECTIONS.PLEASE CALL(209)953-7697 <br /> SIGNED�_-../�TfF"=' TITLE DATE <br /> DATE <br /> EP RTMENT U E ONLY <br /> Application Accepted By Date 114211qArea Employee ID#A�/d <br /> Grout Inspection By Date ❑ PECIAL Well Permit <br /> Pump Inspection By Date n ❑ WAIVER Received <br /> Soil Boring Inspection By Date ` S Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#/ Amount Permit/ <br /> Codes Info Ca h emitted Date Septice eq ueat# Invoice# Well ID# <br /> EHD 43-06 3111/2019 /Jti�O 1 WELL/PUMP PERMIT <br />