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1 �aZ9006 <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 /> I-119-1 J � oobeN 9S 7 y <br /> JOB ADDRESS CITY/ZIP ( m <br /> n 'y s D <br /> CROSS STREET AP//N tO I$`��lW-()"1, PARCEL SIZEB•� 11COLAND USE APPLICATION# A <br /> OWNER NAME / ' f j4�I� �(C l in�i—4, PHONE �( �! <br /> AF <br /> OWNER ADDRESS �v I _�n/ 2—C. CITY/STATE/ZIP /L e d I "'�L / <br /> CONTRACTOR 1`�C.�� Orrl1`^� � ,D.N �P,JHONE r+Myr\l I-slo <br /> CONTRACTOR ADDRESS 9b a duff{N�a\ V\I� CITY/STATE/ZIP W Z "ITNO <br /> !"11 O <br /> SUBCONTRACTOR/CONSULTANT //►� P�H1O/NrE^�. �l <br /> SUBCONTRACTOR/CONSULTANT ADDRESS CITY/STATE/ZIP •_•1/ n t <br /> LICENSE �(C-57 C-61 D-09 : Other NUMBER <br /> IO4w to EXPIRATION DATE 67-sl-20 21 <br /> BILLING PARTY: ,OWNER CONTRACTOR SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING: _ General Mineral/Coliform Bacteria(4391)- Dibromochloropropane(4392)- Arsenic(4393) <br /> INTENDED USE Domestic/Phvate 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 I Well Alteration/Modification Other <br /> Monitoring Well(s) #of wells I Soil Boring(s) a of borings xGeotechnical a of borings <br /> Out-Of-Service Well I Out-Of-Service Well Renewal Cross-Connection Repair <br /> New Pump Pump Replacement I Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method `,Mud Rotary Air Rotary Y.Au er Cable Tool ❑ Push Point Other <br /> �. <br /> Proposed Well Depth g ft Excavation �� in diameter ❑ Open Bottom Gravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_ in Thickness/Gauge/ASTM Sched Steel I Plastic I 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 -1 <br /> Other 1Cbry+,IC 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 Submersible Turbine Other HP Pump Set ft Standing Water Level ft <br /> 1 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 ,�IwMU 8 HOU{�� ADVANCE NOTICE REQUIRED FOR INSPECTIONS -PLEASE CALL(209)) 9 3-7 97 A�e E N T <br /> SIGNED V_C/ , y!���✓�v`T� TITLE (4 0I0g,S DATE �G (,& �� li/I a <br /> � ED <br /> 3 2020 <br /> N JOAQUIN COUNTY <br /> I VI O MENTAL <br /> PARTMENT <br /> v <br /> DEPARTMENT USE PNLY 1 <br /> Application Accepted By `v Date / LU Area Employee ID# <br /> Grout Inspection By Date SPECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> ^9- Date ?)� �� ?v Constructed Well ft <br /> Soil Boring Inspection By <br /> COMMENTS �A,f✓.rli�t M1� 70 //m/zul�� <br /> PE Sc Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info By Cash Remitted Service Request# <br /> 17"o O I 2 <br /> 0 <br /> EHD 43-06 6/1112019 WELL/PUMP PERMIT <br /> �3 2 8 2020 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> 'Ar Al T'i'li.t3A?T.'YiG6'T <br />