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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 hEXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS b 1 C CITY/ZIP <br /> q 7 / D <br /> CROSS STREE 7"!G•{1S(� L'IH _PpN r��� �{ �('�Z PARCEL SIZE i�• 1`LAND USE APPLICATION# p <br /> nn`` A <br /> OWNER NAME Gl�`fy}- ��,�[_•�[ PHONE&:�L l -•��-L�[ in <br /> OWNER ADDRESS 7-; L2 1'7'c�j 5,-� 1-��(-� CITYISTATE/Zff �� <br /> CONTRACTOR , F%'�, ,/ (�[�lj � PHONE 11 �"' <br /> CONTRACTOR ADDRESS >=l 1 '��L!'�s'`'�jZ l �j�� � <br /> r � CITY/STATE/ZIP /���� <br /> SUBCONTRACTORICONSULTANT 4 -f PHONE <br /> SUBCONTRACT/OR/CONSULTANT ADDRESS CITY/STATE/ZIP <br /> LICENSE �( C-57 11 C-61 D-09 -1 Other NUMBER EXPIRATION DATEL- <br /> BILLING PARTY: D OWNER D CONTRACTOR SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING:CI General Mineral/Coliform Bacteria(4391)0 Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE Domestir/Private U Irrigation/Agricultural Industrial 0 Water Quality Monitoring Soil Sampling/Characterization <br /> If aiHerenl from Owner: Water System Name Contact Nam <br /> e or Phono Number <br /> TYPE OF WORK New Well :Replacement Well 1 I Well Alteration/Modification 'Other r <br /> Monitoring Well(s) If of wells n Soil Boring(s) #of b°ringseo ec ni I #of borings <br /> Out-Of-Service Well L Out-Of-Service Well Renewal Cross-Connection Repair <br /> New Pump PUMP Replacement L Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION / <br /> Drilling Method Mud Rotary Air Rotary ` Auger Cable Tool i Push Point •—"KOther <br /> Proposed Well Depth i ft Excavation in diameter I Open Bottom Gravel Pack/Gravel Size in diame <br /> Conductor Casing in diameter / Conductor Casing Depth it ,1 i <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched A-cl— Steel Plastic Stainless Steel :.'Other <br /> Grout Seal Depth ; ft Neat Cement(94 Ib bag/5-10 gal water) _ Sand Cement sack mix/7 gal wO� <br /> Bentonite(20%solids) Other 2020 <br /> Grout Placement Metho Pumped Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller Pump Contractor Other Q "IR YECOuNTY <br /> Concrete Pedestal Dimensions:Width ft Length ft Thick in Christy Box Stove Pip QNj <br /> PUMP Submersible Turbine Other HP Pump Set ft Standing Water Level it <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 C IFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> 11NIMUM 48 HO1J AD NCE TICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-76+9' <br /> SIGNED TITLE,FV,' ->( (�j 1�( DATE <br /> f <br /> DEPARTMENT U E ONLY ,`�T <br /> Application Accepted By � Date Z`7`7 Area / r> Employee ID# <br /> Grout Inspection By 7t 1. /` Date ��i` SPECIAL Well Permit <br /> Pump Inspection By / Date WAIVER Received <br /> Soil Boring�oPpection By / n.m Constructed Well Depth ft <br /> COMMENTS J%4111s#'.0 b.IPI ([n o�M 119�+�rg -jo v7 x!l jo M1�( Ar,4 ' j W <br /> --T <br /> PESC Received Amount Date Permit/ # Well ID# <br /> Codes Info Cas Remitted ae Service Re uest <br /> EHO 43-06 611112019 WELLIPUMPPERMIT <br />