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w <br /> 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 /> ee q ` � <br /> JOB ADDRESS 216 vf.'1'p4rleLD .4VE CITY/ZIP M41vfE[A /T73p m <br /> .„L1-go 414P n <br /> CROSS STREET MIK f fL L 4-6 APN 121-D9b.2m PARCEL SIZE 17-r7 LAND USE APPLICATION# 0 <br /> m <br /> OWNER NAME .�'l�.".c L-4 VN r iev syijoo , pjpl_i.f It PHONE d ren <br /> OWNER AD ESS '2Z�) w� LOVIS 4-'•E CITY/STATE/ZIP _,"*­'ftC±4 , Cf 1jr07 <br /> W TL_ k/4I.�CF fV f 4ffoU PHONE"?/& ?n-/rYYy <br /> DDRES3 7�� N -Y( t� CITY/STATE/ZIP 1/• J 4L C-� p�J�Qf <br /> V 41LLIa�f�- ��t/e_ PHONE(2 0�Vi - 77c* <br /> SS �J� 11,41 J:KL14--IY 911 CITY/STATE/ZIP GC'4 <br /> AU--/ , <br /> LICENSE 51 11C-61 ❑ D-09 0 Other NUMBER 72D9 07 EXPIRATION DATE <br /> BILLING PARTY: OWNER ONTRACTOR UBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391)i. Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE ❑ Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ 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 of borings <br /> ❑ Out-Of-Service Well 11 Out-Of-Service Well Renewal D Cross-Connection Repair <br /> F1 New Pump ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method ❑ Mud Rotayy CI Air Rotary VAuger ❑ Cable Tool ❑ Push Point 1.1 Other <br /> Proposed Well Depth b ft Excavation in diameter 0 Open Bottom ❑ Gravel Pack/Gravel Size in diameter <br /> D Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_ in Thickness/Gauge/ASTM Schad ❑ Steel ❑ Plastic ❑ Stainless Steel ❑ Other <br /> Grout Seal Depth (o ft X Neat Cement(941b bagl5-10 gat water) ❑ Sand Cement sack mix/7 gal water <br /> D Bentonite(20%solids) ❑ Other <br /> Grout Placement Method I1 Pumped XFree Fall Other [ F && etar Aetor(name) <br /> PEDESTAL Installed By ❑ Driller D Pump Contractor ❑ Other <br /> ❑ Concrete Pedestal❑Dimensions:Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe <br /> PUMP ❑ Submersible❑ Turbine U 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. 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 /> MINIMUM 48 HOU ADVANCE NOTICE REQUIRED FOR INSPECTIONS -PLEASE CALL(209)953-7697 <br /> SIGNED TITLE DATE <br /> 17) <br /> U/ <br /> _ O <br /> T <br /> EP RTMENT USEONLY <br /> Application Accepted By Date4ell Area Employee ID# __ <br /> Grout Inspection By Date SPECIAL Well Permit <br /> Pump Inspection By Date ' ' WAIVER Received <br /> Soil Boring Inspection Byek � Date tk a Constructed Well Depth _ it <br /> COMMENTS 1� <br /> PE SC Received Amount at Permit/ Invoice# Well ID# <br /> Codes Info B Cas Remitted Service Re uest# <br /> 2 '2, <br /> EHD 43-06 6111/2019 WELL/PUMP PERMIT <br />