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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1668 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232(209)468-3420 <br /> NON-REFUNDABLE PERMIT www.slgov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 7_9,U_050 W Pe$caAere Ave CITY/ZIP TY��rj <br /> D <br /> CROSS STREET parg C1 St I!J APN 13 1J�D�%O PARCEL SIZE LAND USE APPLICATION# A <br /> OWNER NAME C` �I�'L V �'I 1 •�• �f PHONE /1 �a <br /> OWNER ADDRESS 3 5 '-IV1� (.2 y11C11 (J1 r&GLC: CITY/STATE/ZIP /h <br /> CONTRACTOR Kelinfelder PHONE 209-981-7755 <br /> CONTRACTOR ADDRESS 2001 Arch Airport POrt,Suite 100 CITY/STATEIZIP Stockton,CA,95206 <br /> SUBCONTRACTORICONSULTANT V and W Drilling PHONE 209-981-7755 <br /> SUBCONTRACTOR/CONSULTANT ADDRESS 1133 Blackhurst Dr CITY/STATEIZIP Galt,CA,65632 <br /> LICENSE N C-57 CI C-61 D D-09 L Other NUMBER 720804 EXPIRATION DATE 04/30/2020 <br /> BILLING PARTY: D OWNER X CONTRACTOR C SUBCONTRACTORICONSULTANT <br /> DOMESTIC WELL SAMPLING:C General Minoral/Coliform Bacteria(4391)C Dibromochloropropane(4392)❑Arsenic(4393) <br /> INTENDED USE C Domestic/Private J Irrigation/Agricultural ❑Industrial 0 Water Quality Monitoring C Soil Sampling/Characterization <br /> L Public Water System <br /> If 6rferent from Owner. Water Syslem Name Contact Name or Phone Number <br /> TYPE OF WORK C Now Well ❑Replacement Well 7 Well Alteration/Modificallon ❑Other - <br /> C Monitoring Well(s) #of wells 7 Soil Bodng(s) aolboring, X Geotechnical of boring, <br /> C Out-Of-Service Well 7 Out-Of-Service Wall Renewal D Cross-Connection Repair <br /> L New Pump L Pump Replacement J Pump Repair [I Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method x Mud Rotary I I Air Rotary x Auger 11 Cable Tool I Push Point I, Other <br /> Proposed Well Depth_5 0 It Excavation in diameter I Open Bottom 7 Gravel Pack/Gravel Size in diameter <br /> r Conductor Casing In diameter / Conductor Casing Depth R <br /> Well Casing Diameter_In Thlckness/Gaugo/ASTM Schad J Steel J Plastic L Stainless Steel L Other <br /> Grout Seal Depth e_5() ft X Neat Cement(94 Ib bag/5-f0 gal water) ❑Sand Cement sack mixr7 gal water <br /> C Bentonite(20%solids) ❑Other <br /> Grout Placement Method X Pumped C Free Fall C Other C Retardant I Accelerator(name) <br /> PEDESTAL Installed By u Duller J Pump Contractor I Other <br /> L Concrete Pedestal LDlmenslons:Width fl Length ft Thick in O Christy Box u Stave Pipe <br /> PUMP I Submersible)I Turbine I Other HP Pump Set it Standing Water Level K <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 /> MI IM 8 HOUR ADVAN E NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED TITLE Project Professional DATE <br /> E�MFNT <br /> I 3A R 3 ?020 <br /> QU//v <br /> DEpq TMEN 7Y <br /> T <br /> T / DEPARTMENT USE ONLY <br /> H / - S ZoZO T;<`c n <br /> Application Accepted By Date Area " Employee ID# r <br /> Grout Inspection By Date ❑ SPECIALWell Permit <br /> Pump Inspection By Dale ❑ WAIVER Received <br /> Soil Boring Ipspecllor�By L11. Dale 7 ? Z Constructed Well Depth ft <br /> COMMENTS -/L L-v rGrtli r t v• P aWlV, III jS' 4i"r'/r <br /> PE SC Received Check#/ Amount 0 to Permit/ Invoice# Well ID# <br /> Codes Info Cash Remitted Service Request# <br /> `13/d 1. J .I�� i `✓ <br /> EMD 4306 6/11/2019 WELL/PUMP PERMIT <br />