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r , <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.sigov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> ^� m <br /> JOB ADDRESS ��d'$ �L�-Q e0 1 Vye Cm/LP 95 3 pLi__ — <br /> p D <br /> CROSS STREET Dar a A. APN 21:3—070—7 PARCEL SIZE LAND USE APPLICATION k m <br /> OWNER NAMEY PHONE / !? <br /> OWNER ADDRESS l�lyj0 Gen}er rICrZ4l CITYISTATEIZIP <br /> CONTRACTOR Kellnfelder PHONES 209-981-7755 <br /> CONTRACTOR ADDRESS 2001 Arch Airport POrt,Suite 100 CITY/STATE/ZIP Stockton,CA,95206 <br /> SUBCONTRACTOR/CONSULTANT V and W Drilling PHONE 209-981-7755 <br /> SUBCONTRACTOR/CONSULTANT ADDRESS 1133 Blackhurst Or CITY/STATEIZIP Galt,CA,65632 <br /> LICENSE x C-57 11 C-61 I D-09 I Other NUMBER 720904 EXPIRATION DATE 04/30/2020 <br /> BILLING PARTY: _1 OWNER X CONTRACTOR C SUBCONTRACTORICONSULTANT <br /> DOMESTIC WELL SAMPLING:L General Mineral/Coliform Bacteria(4391)i Dibromochloropropane(4392)J Arsenic(4393) <br /> INTENDED USE Domestic/Private ,Irrigation/Agricultural 11 Industrial ❑Water Quality Monitoring Soil Sampling/Characterization <br /> Public Water System <br /> If dfflereM from Ower. Water System Name Contact Name or Phone Number <br /> TYPE OF WORK F New Well ❑Replacement Well -Well Alteration/Modification ❑Other <br /> Monitoring Well(s)---- flof wells Soil Boring(s). n of borings X Geotechnical � p of twrings <br /> Out-Of-Service Well Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> New Pump L. Pump Replacement Pump Repair D Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method x Mud Rotary Air Rotary x Auger I Cable Tool I Push Point Other <br /> Proposed Well Depth__3_0__It Excavation __In diameter Open Bottom Gravel Pack/Gravel Size __in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth R <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched _ Steel Plastic Stainless Steel Other_ <br /> Grout Seal Deprho-3i)_fl x Neat Cement(94 lb bag/5-10 gal Water) a Sand Cement sack mixr7 gal water <br /> Bentonite(20%solids) !!Other <br /> Grout Placement Method X Pumped Free Fall 7 Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller -Pump Contractor Other <br /> Concrete Pedestal :Dimensions:Width It Length ft Thick in Christ Box Stove Pipe <br /> PUMP Submersible Turbine Other HP Pump Ser ft Standing Water Level ft <br /> I HEREBY CERTIFY THAT 1 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. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MINIMU OUR ADVANCE NOTI E REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953.7697 <br /> SIGNED TITLE Project Professional DATE 3/ 1771 <br /> RE yM47 <br /> CE�V�D <br /> MAR 3 ?020 <br /> O4 QU/ <br /> H H E gRrM� <br /> ENr <br /> DEPARTMENT USE ONLY -/ <br /> Application Accepted By 1, Dale S131LZoZ0 Area 5 /7`'e t Employee ID# <br /> Grout Inspection By I Date ❑ SPEC AL Well Permit <br /> Pump Inspection By - Dale ZV ❑ WAIVER Received <br /> Soil Boring Inspeclior By L Lpate -Gconslructed Well Depth ft <br /> COMMENTS L':,(- y G. a J,e ('. 7! Q •.':YLIfRo C,V jh) ' (`:i k'. IJ It, L) P O <br /> ,(rt re — <br /> PE Sc Received Check#/ Amount ate Permit/ Invoice# Well ID# <br /> Codes Info Cas Remitted Service Request# <br /> =1Z.iv i�0 rI. � v '•C <br /> EIID X706 6/1,12019 WELL e'UAIP PERMIT <br />