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DO WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232(209)468-3420 <br /> NON-REFUND BLE PERMIT www.sjgov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> / m <br /> JO Gh 6K CITY/ZIP <br /> D RE m <br /> D <br /> CROSS STREET APN PARCEL SIZE LAND USJE APPLICATION# z <br /> OWNER NAME i PHONE <br /> OWNER ADDRESS CITY/STATE/ZIP <br /> CONTRACTOR n ��\t2 PHONE <br /> CONTRACTOR ADDRESS '[�_I 10--A �V\6Y'f R��IA\` (�G CITY/STATE21P�TL„. ��a��1,�6 <br /> SUBCONTRACTOR/CONSUL/T-ANNT�Jt_ — e 'r�/PHONF <br /> SUBCONTRAC�TOORICONSULTANT ADDRESa_ CITY/STATEIZP yy -`rl � <br /> LICENSE LS C:-b7 D C-61 ❑D-Cu V[ner NUMBER �l — EXPIRATION DAT_ L 1— <br /> BILLING PARTY: D OWNER D CONTRACTOR D SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING:D General Mineral/Coliform Bacteria(4391)❑Dibromochloropropane(4392)❑Arsenic(4393) <br /> INTENDED USE D Domestic/Private D Irrigation/Agricultural ❑ Industrial D Water Quality Monitoring Qtoll Sampling/Characterization <br /> D Public Water System <br /> If different from Owner. Water System Name Contact Name or Phone Number <br /> TYPE OF WORK ❑New Well ❑Replacement Well D Well Alteration/Modification D Other <br /> D Monitoring Well(s) #of wells D Soil Boring(S) #of borings Geotechnical #of borings <br /> D Out-Of-Service Well D Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> D New Pump ❑Pump Replacement 7 Pump Repair C Raise Well Casing <br /> WELL CONSTRUCTION <br /> / <br /> Drilling Method Y Mud Rotary C Air Rotary v3 Auger D Cable Tool VlP sh Point C Other <br /> Proposed Well DepthI%a ft Excavation in diameter 7 Open Bottom ❑Gravel Pack/Gravel Size in diameter <br /> I I Conductor Casing in diameter / Conductor Casing Depth ft ` <br /> Well Casing Diameter lij Thickness/Gauge/ASTM Sched 7 Steel 7 Plastic ❑Stainless Steel E)Other <br /> Grout Seal Depth lft Meat Cement(94 Ib bag/5-10 gal wafer) -1Sand Cement sack mix(1 gal w d 1 •Y <br /> ❑Bento ( o solids) C Other <br /> Grout Placement Method V15umped C Free Fall Othe C Retardant/Accelerator(name) <br /> PEDESTAL Installed By D Driller ❑Pump Contractor 7 Other <br /> U Concrete Pedestal LiDimensions:Width ft Length ft Thick in L Christy Box L Stov /9 <br /> PUMP i I Submersible I Turbine I Other HP Pump Set ft Standing Water Level �Y V (,'�U <br /> HEREBY CERTIFY THAT I HAVE PREPARED <br /> IS APPLICATION AND THAT THE WORK WILL BE <br /> NE <br /> AL <br /> CURRENT ANDNACTIIVE TY (WITH ETHESCAL FORNIAHCTATE LAWS, AONTRACTORND RULES S STATED REGULATIONS. <br /> BOARD AND THAT OI AMTIFY TIINYCROMPPLIANCE W THEQUIRSALL pAR MFNry <br /> WORKERS COMPENSATION LAWS. <br /> MINIMU 8 HO ADVANCE NOTICE REQUIRED FOR INSP TIONS-PLEASE CALL(209)953-7697 <br /> x <br /> SIGNED 7 I TITLE 1/) "CX DATE 1 <br /> gALRMENT U E N L Y <br /> ` <br /> Application Accepted By ate Area Employee ID# 1,<W,4 <br /> Grout Inspection By Date ❑ PEC1well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection By kin Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#/ Amount a Permit/ Invoice# Well ID# <br /> odes Info Cash Remitted Service Request# <br /> all T�U At-WO WAVA <br /> EHD 43-06 6/11/2019 WELL(PUMP PERMIT <br />