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/' N� ' 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 /> JOB ADDRESS �J✓l ( h, /,�/ <br /> CITY/ZIP_, 1G--l.�[.- 1 —!--`'[ L� m <br /> CROSS STREET V� p,PN'2`�J ���PARCEL SIZE to �LAND USE APPLICATION# o <br /> OWNER NAMEGtT�C/y-F> <br /> J- PHONEIC� ~tfJ-1 <br /> OWNER ADDRESS Zai C! I-7+ '� `+ `(.�-- CITY/STATEIZIr <br /> CONTRACTOR , F%•� ( � �i h({i,�j r PHONE` <br /> CONTRACTOR ADDRESS S:��J, 1 '4,G.C---,�( c-� /.,�+ ~'�_ � <br /> ..� � �K-� - l CITY/STATE/ZIP e iS �d'_ 425 _ <br /> SUBCONTRACTORICONSULTANT PHONE <br /> SUBCONTR \ACTTOR/CONSULTANT ADDRESS �- CITY/STATE/ZIP <br /> LICENSE �( C-57 I' '� <br /> .C-61 D-09 Other NUMBER EXPIRATION DATE Ci <br /> BILLING PAR/TY: C OWNER I CONTRACTOR SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING:Il General Mineral/Coliform Bacteria(4391)CI Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE Domestic/Private 1_1 Irrigation/Agricultural` Industrial 11 Water <br /> �Quality Monitoring Soil Sampling/Characterization <br /> If tlifferenl from Owner. ! �Water?etemG� Ac A'� `��� �k`� 4 <br /> Y Contact N e or Phone Number <br /> TYPE OF WORK New Well n Replacement Well ,I Well Alteration/Modification ' Other <br /> Monitoring Well(s) #of wells Il Soil Boring(s) i1of borings eo ec ni I N of borings <br /> Out-Of-Service Well L Out-Of-Service Well Renewal 1 1 Cross-Connection Repair <br /> New Pump I Pump Replacement ❑Pump Repair 1 Raise Well Casing <br /> WELL CONSTRUCTION `, /+�1 J i ✓p��� <br /> Drilling Method Mud Rotary Air Rotary -(Auger iL Cable Tool Push Point ~D Other 'T <br /> Proposed Well Depth of S 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 A�_ Steel Plastic Stainless Steel . Other <br /> Grout Seal Depth �JJ`y ft Neat Cement(94/b bag/5-10 gal water) Sand Cement sack mix/7 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Meth4` Pumped 1 Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By i Driller Pump Contractor Other <br /> Concrete Pedestal LDlmenslons:Width ft Length ft Thick in Christy Box Stove Pipe <br /> PUMP Submersible Turbine Other HP Pump Set fl 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 <br /> MINIMUM 8 HCH ,..ADV CE NOTICE REQUIRED FOR <br /> INSPECTIONS-PI-EASE CALL(209)953-7697 <br /> SIGNED Y�'1 TITLE T �-L-T.71,���_` l DATE <br /> FCFjVNT <br /> 14 <br /> ' FO <br /> PR �2 ? <br /> a Q�/N 2020 <br /> CO <br /> NT <br /> Z'_ t——— ———— <br /> DEPARTMENT USE ONLYA--�C'f'T <br /> Application Accepted By 7 Ir Z- Date ,4OZ 7,' Area /,C. Employee ID# <br /> GroutInspection By _ Date I �2� SPECIAL Well Permit <br /> Pump Inspection By. Date WAIVER Received <br /> Soil Boring I spection By Date Constructed WellDepth M <br /> COMMENTS ' ?✓4, .L' '} 161 "!? ? L�'P �'Pl N ' z <br /> h ZJ <br /> PE Sc Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info as Remitted Se ice Re uest# <br /> EHD43-06 6/11/2019 WELL/PUMP PERMIT <br />