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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 /> .�� �� �lAivt�"4 9'533 mo <br /> JOB ADDRESS CITY/ZIP <br /> �� n � �� D <br /> CROSS STREET [// GD�N ♦ V PARCEL SIZE�LAND USE APPLICATION# o <br /> ������� m <br /> OWNER NAME PHONE ui <br /> OWNER ADDRESS C <br /> ITY <br /> y/S <br /> TATE/ZIP Qp <br /> CONTRACTOR ///!/!/��'�5 �7ZJ� �j./��_ PHONE 1�J/ Zorn <br /> CONTRACTOR ADDRESS �0 GV �� -ey'222 CITY/STATE/ZIP <br /> SUBCONTRACTOR/CONSULTANT PHONE <br /> SUBCONTRACTOR/CONSULTANT ADDRESS �_ CIITY(STATE/ZIP e--- <br /> LICENSE 1C-57 )WC-61 ❑ D-09 11Other NUMBER i9 <br /> 1 EXPIRATION DATE P <br /> BILLING PARTY: ❑OWNER ❑CONTRACTOR U SUBCONTRACTORICONSULTANT <br /> DOMESTIC WELL SAMPLING:0 General Mineral/Coliform Bacteria(4391)0 Dibromochloropropane(4392)0 Arsenic(4393) <br /> INTENDED USE ^omestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑Water Quality Monitoring 0 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 Wells) #of wells ❑ Soil Boring(s) #of borings ❑ Geotechnical #of borings <br /> ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> ❑ New Pump oumpReplacement ❑ Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method ❑ Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other <br /> Proposed Well Depth ft Excavation in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel Size In diameter <br /> 0 Conductor Casing in diameter / Conductor Casing Depth It <br /> Well Casing Diameter_ in Thickness/Gauge/ASTM Schad ❑ Steel ❑ Plastic ❑ Stainless Steel ❑ Other <br /> Grout Seal Depth ft ❑ Neat Cement(94 lb bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water <br /> ❑ Bentonite(20%solids) ❑ Other <br /> Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other <br /> ❑ Concrete Pedestal❑Dimensions:Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe <br /> PUMP ubmersible❑ Turbine ❑ Other HP 77Pump 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 /> M �A/N�CCEE�NOTICE REQUIRED FOR 1 SP'�Er,C�TlI'ONS -PLEASE CALL (209) 95 -76 7 <br /> SIGNED_ L/,%�R!%/�f�l_ TITLE /`?"'� '` DATE ✓� Z� <br /> 10 <br /> r <br /> D <br /> S N <br /> _ VI <br /> DE RT ENT S ON LY 7H DEP TM.E <br /> Application Accepted By Date 7�0 Area Employee ID# <br /> Grout Inspection By Date 0 PECIAL Well Permit <br /> Pump Inspection By Date US El WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#/ Amount Permit/ <br /> Codes Info B emitted Date Service Re uest# Invoice# Well ID# <br /> �- 5TZ122D O �1G <br /> EHD 43-06 0/11/2019 WELL/PUMP PERMIT <br />