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WELLIPUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232 (209)468-3420 <br /> NON-REFUNDABLE PERMIT �fwww.sjgov.org/ehd EXPIRES//1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS .04'0 /f/ �/41ii CITY/ZIP (moi" rA yI'D -i <br /> g9 D <br /> CROSS STREET_ APN �"Zj9p0,�&ARCEL SIZE C S tIAND USE APPLICATION# o <br /> L��J4 m <br /> OWNER NAME _ L��/ Z � fZ �+PHONE <br /> �!/ 7!P— ,Q7¢7 <br /> OWNER ADDRESS %�O//J �y� ��fc� p� CITY/STATE/ZIP 2J'!/�/(/ C.�/T g -L/y <br /> CONTRACTOR Z t'/�©4``,/ /mss !/f/ �`7�� P+H.O�NJE, <br /> CONTRACTOR ADDRESSyy!rz-14--81-tl AKD <br /> r� J CITY/STATE/ZIP <br /> SUBCONTRACTOR/CONSULTANT LLL jan-1-1W.6 PHONE <br /> SUBCONTRACTOR/CONSULTANT ADDRESS CITY/STATEIZIP <br /> LICENSE /C -57 -61 ❑ D-09 ❑ Other NUMBER EXPIRATION DATE <br /> BILLING PARTY: ❑OWNER Ll CONTRACTOR ❑ SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING:LI General Mineral/Coliform Bacteria(4391)❑ Dibromochloropropane(4392)FI Arsenic(4393) P <br /> INTENDED USEDomestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characteriza <br /> ❑ Public Water Systern CFV <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK I klNew Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other <br /> ❑ Monitoring Well(s) #of wells LI Soil Boring(s) #of borings <br /> ❑ Geotechnical <br /> Out-Of-Service WPll 0 um Replacement ❑ PumRepair i� ❑ Raise Well Cas <br /> Out-Of-Service Well Renewal Cross-Connection <br /> Repair <br /> ❑ New Pum <br /> WELL CONSTRUCTION MFN <br /> Drilling Method XMud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other <br /> Proposed Well Depth�ft Excavation /z,, in diameter ❑ Open Bottom Gravel Pack/Gravel Size in diameter <br /> ❑ Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter-10— in Thickness/Gauge/ASTM Sched 4f ZM) ❑ Steel ,A�Plastic ❑ Stainless Steel ❑ Other <br /> Grout Seal Depth /pfd ft ❑ Neat Cement(94 lb bagl5-10 gal water) ❑ Sand Cement sack mix17 gal water <br /> �$1Bentonite(20%solids) ❑ Other <br /> Grout Placement Method Atumped ❑ Free Fall ❑ Other ❑ Retardant/Accelerator(name) <br /> 1��77 <br /> Installed By ❑ Driller ump Contractor ❑ Other <br /> ❑ Concrete Pedestal L IDi pensions:Width—42--ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe <br /> PUMP ubmersible❑ Turbine ❑ Other HP Pump SeL__&a.ft Standing Water Level 39—f7!!--1 <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 /> M=8 ADVANCE NOTICE REQUIRED FOR INSPECTIONS -PLEASE CALL(209)Pj <br /> 76 <br /> SIGNED L fL/r`; fig - - /�./�G�L DAIE _ � l - t` <br /> / y/ <br /> I I Ig l•7/ ` �r � <br /> It r <br /> 21 <br /> 3� z� <br /> .�75�j�� it ,(/t <br /> le <br /> �z6 fa�w <br /> . PARTMENT U E ONLY <br /> Application Accepted By Date el Area Employee ID#_Q <br /> Grout Inspection By a Date t ❑ ECIAL Well Permit <br /> Pump Inspection By �f��,.51s� �P Ya�r.0 Date r���iI-Lai,0 CI WAIVER Received <br /> Soil Boring Ins ection By Dle Constructed Well Depth ft <br /> COMMENTS %�TWQI�- 66 �•f?�1�"-( - •- � � � <br /> PE SC Received C V Amount Date Permit/ Invoice# Well ID# <br /> Codes Info By_ Cash Remitted Service Request# <br /> 3 l 03 3 <br /> ^ A1113119 MOO � <br /> 13 I Iq W p <br /> 1113119 W D 00 <br /> H 43-0151 6/11/2019 WELL/PUMP PERMIT <br />