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` ®\� EYED 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-11 YEAR FROM DATE ISSUED <br /> JOB ADDRESS N <br /> CROSS STREET 1!_14N%A011 APN �6 PARCELSIZEZ2•(; LAND USE APPLICATION# <br /> OWNER NAME ' _ PHON�E'' `i <br /> OWNERADDRESST� CITY/STATEIZIP Q <br /> 1 pp����� <br /> CONTRACTOR _Vlo i,,Q _._ f'nm� PHONE ,CI 01.a_ <br /> CONTRACTORADDRESSFo,y�_�V(�r,.A1Y POY�f !o(, CITY/STATEIZIP <br /> SUBCONTRACTORICONSULTANTY�A� �.\�'A '` PHONE o ' <br /> SUBCONTRACTORICONSULTANT ADDRESS�5 a )A"awe �� CITYISTATE//ZZJPI A a4i A Pg ISI1 65 3 <br /> LICENSE V47 ❑C-61 ❑D-09 DD�Other NUMBER`A i��l A EXPIRATION DATE Zo�o- _. <br /> BILLING PARTY: 0OWNER \RrCONTRACTOR ❑ SUBCONTRACTORICONSULTAAN"-T�T <br /> DoMEsnc WELL SAMPLING:❑General Mineral/Coliform Bacterla(4391)0 Dibromochloropropane(4392)❑Arsenic(4393) <br /> INTENDED USE D Domestic/Private ❑Irrigation/Agricultural D Industrial D Water Quality Monitoring Idtoil Sampling/Characterization <br /> D Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK 0 New Well D Replacement Well D Well Alteration/Modification D Other <br /> ❑Monitoring Well(s) #of wells D Soil Bodng(s) #of borings 11,<I-eotechnical #of borings <br /> 0 Out-Of-Service Well D Out-Of-Service Well Renewal D Cross-Connection Repair <br /> D New Pump D PumpReplacement 7 Pump Repair C Raise Well Casing <br /> WELL CONSTRUCTION � <br /> Drilling Method D Mud Rotary C Air Rotary 7 Auger D Cable Tool t-lPush Point C Other <br /> Proposed Well Depthft Excavation In diameter 7 Open Bottom D Gravel Pack/Gravel Size in diameter <br /> I I Condu or Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_ in Thickness/GaugelASTM Schad 7 Steel 7 Plastic D Stainless Steel D Other <br /> Grout Seal Depth�mft %1<9t Cement(94 Ib bag/5-10 gal water) D Sand Cement sack mW7 gal water <br /> D Bentonite(20%solids) C Other <br /> Grout Placement Method%Wfumped C Free Fall Other C Retardant/Accelerator(name) ee <br /> PEDESTAL Installed By D Driller D Pump Contractor 7 _4 <br /> Other Y <br /> U Concrete Pedestal uDimensions:Width it Length it Thick in L Christy Box L Stove Pipe 4 <br /> PUMP I I Submersible I Turbine I Other HP Pump Set ft Standing Water Level it <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SA <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. 1 ALSO CERTIFY THAT MY REQUIRED LICEN;$g IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITW 4L <br /> WORKERS COMPENSATION LAWS. <br /> MINI MM 4�ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-76971 Cq�T OS ACOU� <br /> SIGNED TITLE �'F(g ✓»'n119/f «.r DATE y�FART� <br /> EP RTMENT U E DNLY <br /> e <br /> Application Accepted By / Date Area Employee ID# <br /> Grout Inspection By Date ❑ PECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection By o Date ZZ Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#/ Amount Permit] <br /> Cods Info Ca a itte Date ervice Request# Invoice# Well 1D# <br /> EHD43306 6111/2019 - WELL/PUMP PERMIT <br />