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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205$232 (209)468-3420 <br /> NON-REFUNDABLE PERMIT www.sloov.org/ohd EXPIRES 1 YEAR FROM DATE ISSUED <br /> Joe ADDRESS Cm/ZIP Stockton/95219 �D <br /> CROSS STREET N 11602001 PARCEL SIZE 18.01 LAND USE APPLICATION# A <br /> N <br /> OWNER NAME PHONEL .0 <br /> OWNER ADDRESS R-0 OCK fl7 CITY/STATE/LP #UNl7r& <br /> CONTRACTOR Weinfelder PHONE 209-946-1345 <br /> CONTRACTOR ADDRESS 2001 Arch Airport Road CITY/STATE/LP SIOCkton,CA 95206 <br /> SUBCONTRACTOR/CONSULTANT Gregg Drilling PHONE 925-313-5800 <br /> SUBCONTRACTOR/CONSULTANTADDRESS 950 Howe Road CITY/STATE/LP Martinez,CA 94553 <br /> qV] <br /> LICENSE W C-57 I]C-61 00-09 D Other NUMBER I=W-(L1 L4rL`RPIRATION DATE-VJ4k'W 7 2t <br /> 11 <br /> ,BILLING PARTY: D OWNER M CONTRACTOR D SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING:D General Mineral/Coliform Bacteria(4391)0 Dibromochloropropans(4392)0 Arsenic(4393) <br /> INTENDED USE 0 DomesticfPdvate D htlgation/Agricullural D Industrial 0 Water Quality Monitoring I(Soll Sampling/Characteriza6on <br /> 0 Public Water System <br /> It different from Owner: Weler Syelem Name Contact Name or Phone Number <br /> TYPE OF WORK 0 New Well D Replacement Well 0 Well Alteration/Modification 0 Other �ra�.y <br /> 0 Monitoring Well(s) #of wells D Soil Boring(s) M of bodnoa R Geotechnical �► O of benne' <br /> 0 Out-Of-Service Well D Out-Of-Service Well Renewal 0 Cross-Connection Repair 2 bogy,At S <br /> New Pump n Pump Replacement D Pump Repair 1 Ralso Well Casing SGPTS <br /> WELL CONSTRUCTION <br /> Drilling Method V Mud Rotary I]Air Rotary 0 Auger D Cable Tool W Push Point 0 Other <br /> Proposed Well Depth 60 ft Excavation 1-5-6 In diameter D Open Bottom D Gravel Pack/Gravel Size in dinmca�r <br /> 0 Conductor Casing In diameter / Conductor Casing Depth ft <br /> Well Casing Diamete In Thickness/Gauge/ASTM Schad D Steel 0 Plastic D Stainless Steel 0 Other <br /> Grcut Seal Depth. Cf Neat Cement(94 11;bagl5-10 gal water) D Sand Cement sack m/x/7 gal water <br /> D BenXite(20%solids) D Other <br /> Grout Placement Method W Pumped D Free Fell Other 0 Retardant/Accelerator(name) <br /> PEDESTAL Installed By Cl Driller 0 Pump Contractor Li Other _ <br /> 0 Concrete Pedestal ODlmenslons:Width ft Longlh ft Thick in D Christy Box Stove Plpo <br /> PUMP 0 SubmerslbleD Turbine 0 Other HP Pump Sal R Standing Water Level h <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 /> MINI AS k10 ADyANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED �— TITLE ' f C� / )LtGvtL2 DATE 11(7 12-11-- <br /> � <br /> 71 <br /> MENT <br /> IVES <br /> 2020 <br /> TMENT <br /> AeR M E N T S LY <br /> Application Accepted By Date Aree ��-_ Employee ID#� <br /> Grout Inspection By Dale ❑ SPECIAL Well Permit <br /> Pump Inspection By Data ❑ WAIVER Received <br /> Soil Boring Inspection By 91 41"tirL Date Z 6 Constructed Well Depth __ft <br /> COMMENTS <br /> PE 5C Received Check#/ Amount Date Permit] Invoice# Well IDN <br /> Codes Info By 0 Casherntta ervlce ttaquest# <br /> L <br /> EHO/7-OB BI11rlOte � i �/r����/ /Y WELL(PUMP PERMIT <br />