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G � /0�j� <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.sigov.org/ehd EXPIRES-1 YEAR FROM DATE ISSUED <br /> rn <br /> JOB ADDRESS ') t 1 JY CnY21P m <br /> IF D <br /> CROSS STREET APN '/ !1 I h P IL PARCEL SIZE Q LANG USE APPLICATION# 0 <br /> J <br /> OWNER NAME <br /> 1 1 !ur _ 'i ) PHONE <br /> - <br /> OWNER ADDRESS / Z CITY/STATEIZIP QAll <br /> v� E'ttj��l 1 <br /> CONTRACTOR ` PHONE-���a31 <br /> CONTRACTOR ADDRESS 1A !` g7�V(1..F' 1 l-`A � ��ed, CIN/STATE/ZIP CJ- 10l)-, ��}Y� <br /> SUBCONTRACTORICONSULTANT�Y � C�Y�®L.�G: PHONE1 a13 - csC� <br /> SUBCONTRACTOR/CONSULTANT ADDRESS -�fl�✓= �� CITYISTATE/ZIP.M L1�' d GI Pi �-_L /91 L ?j <br /> LICENSE VC-57 0 C-61 0 D-09 ❑0 Other NUMBER�•D, EXPIRATION DATE �q��� <br /> BILLING PARTY: 0 OWNER VQ CONTRACTOR D SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING:0 General MlneraVCol'Iform Bacteria(4391)❑Dibromochloropropane(4392)D Arsenic(4393) <br /> INTENDED USE ❑Domestic/Private 0 Irrigation/Agricultural 0 Industrial 0 Water Quality Monitoring oil Sampling/Characterization <br /> 0 Public Water System <br /> If different from Owner. Water System Name Contact Name or Phone Number <br /> TYPE OF WORK 0 New Well 0 Replacement Well D Well Alteration/Modification 0 Other <br /> ❑Monitoring Well(s) #of wells ❑Soil Boring(s) #ofbodngs tio<eotechrilcal #ofbodngs <br /> ❑Out-Of-Service Well D Out-Of-Service Well Renewal 0 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 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 Condu or Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Schad 7 Steel 7 Plastic 0 Stainless Steel ❑Other <br /> Grout Seal Depth 0 ft 991e9at Cement(94 Ib bag/5-10 gal water) -1 Sand Cement sack mbr/7 gal water <br /> ❑Bentonite(20%solids) C Other <br /> Grout Placement MethodWi umped C Free Fall Ix Othe C Retardant/Accelerator(name) <br /> PEDESTAL Installed By 0 Driller D Pump Contractor 7 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. 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. /Q <br /> MINI M H U ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED TITLE �kf4 'in.f"ty.0go DATE <br /> V <br /> DSP'4R At <br /> A MENT U N L Y <br /> Application Accepted By 4&fftaateArea Employee ID# Tit 1 <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection By orl Date ❑ WAIVER Received . <br /> Soil Boring Inspection By Date�L��"�9 Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#/ Amount Permit/ <br /> ods Info Cas ittDate Spkvice Re uest# Invoice# Well ID# <br /> EHD 43-08 811112019 � ��i ""' � I �/D" ( ��� WELL(PUMP PERMIT <br />