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4 <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 VVWW.S OV.0r /ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> w <br /> JOB ADDRESS S-a D ✓ CITY/ZIP 4. G <br /> ��//!J1� <br /> A C D <br /> CROSS STREET ZZO APN /f IO~� PARCEL SIZ�LAND USE APPLICATION# o <br /> m <br /> OWNER NAME !C O(, PHONE <br /> OWNER ADDRESS ,3'�l' S4' - Qer /�,�Y/ CITYISTATE2IP 9 r/Ar/L/ C� Y11 2, <br /> CONTRACTORI,i/� PHONE <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> SUBCONTRACTOR/CONSULTANT PHONE <br /> SUBCONTRACTOR/CONSULTANT ADDRESS CITYISTATEIZIP <br /> LICENSE iJ C-57 _i C-61 i D-09 Other NUMBER EXPIRATION DATE <br /> BILLING PARTY: U OWNER EI CONTRACTOR U SUBCONTRACTORICONSULTANT <br /> DOMESTIC WELL SAMPLING:_:General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392)C1 Arsenic(4393) <br /> INTENDED USE PomesticlFrivate Irrigation/Agricultural r Industrial ` Water Quality Monitoring Soil Sampling/Characterization <br /> -i Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK New Well Replacement Well Well Alteration/Modification i_j Other <br /> Monitoring Well(s) #of wells Soil Boring(s) #of borings i i Geotechnical If of borings <br /> Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair <br /> New Pump Pump Replacement Pump Repair Raise Well Casing <br /> WELL CONSTRUC ON <br /> Drilling Method D Mud Rotary Air Rotary Auger Cable Tool Push Point Other <br /> Proposed Well Depth It Excavation in diameter Open Bottom Gravel Pack/Gravel Size in diameter <br /> 0 Conductor Casing in diameter / Conductor Casing Depth It <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Schad D Steel 0 Plastic Stainless Steel I_Other <br /> Grout Seal Depth ft Neat Cement(94 Ib bag/5-10 gal water) 0 Sand Cement sack mixl7 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method _Pumped _Free Fall 0 Other C Retardant/Accelerator(name) <br /> PEDESTAL Installed By -'Driller '.7 Pump Contractor Other <br /> Concrete Pedestal 'Dimensions:Width It Length It Thick in D Christy Box 0 Stave Pipe <br /> PUMP *bmersible❑Turbine a Other HP Pump Set It 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. 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 /> MINIMUM{ HOIKADVeCE ryep•E IRED FOR INSPECTIONS-PLEASE CALL(209)953-76/9{7 <br /> SIGNED G L f t`(�99�` TITLE LJiKDATE t�'�V <br /> R� ��� l <br /> C oVPA <br /> ® �o'o <br /> OAQ1�/ <br /> C IR�Nti EC0U'V Y <br /> �EpAR MENT <br /> AR MENT SY <br /> Application Accepted By / Date Z(7 Area Employee 1D# <br /> Grout Inspection By p Date PECIAL Well Permit <br /> Pump Inspection ByDate—•� WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC ReceivedtblAmount Date Permit/ Invoice# Well ID# <br /> Codes Info ash Remitted S rvice Re u # <br /> EH043-06 6/1112019 WELL/PUMP PERM IT <br />