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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.S V.O P/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> N <br /> JOB ADDRESS CIN/ZIP m <br /> 1/ / ` D <br /> CROSS STREET V —1!�O APN Z'J I 0SVI ARCEL SIZE 191 LAND USE APPLICATION# I A <br /> OWNER NAME T PHONE 936--a t (. m <br /> OWNER ADDRESS CITY/STATE/ZIP A4 CA9 -763-11:2 <br /> oul <br /> CONTRACTOR PHON�✓yJ�n_ <br /> CONTRACTOR ADDRESS / CITY/STATE/ZIP L�AI�A///C� <br /> SUBCONTRACTOR/CONSULTANT PHONE <br /> SUBCONTRACTO /CONSULTANT ADDRESS C S T /ZIP <br /> — AAF114-- <br /> LICENSE 57 O C-61 ❑D-09 ❑Other NUMBER EXPIRATION DATE <br /> BILLING PA TY: O OWNER D CONTRACTOR D SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL I <br /> AMPLING:❑General Mineral/Coliform Bacteria(4391)D Dibromochloropropane(4392)0 Arsenic(4393) <br /> INTENDED USE Domestic/Private ❑Irrigation/Agricultural ❑Industrial D Water Quality Monitoring ❑Soil Sampling/Characterization <br /> Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK 0 New Well ❑Replacement Well ❑Well Alteration/Modification ❑Other <br /> ❑Monitoring Well(s) #of wells ❑Soil Boring(s) #of borings ❑Geotechnical #of borings <br /> ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> ❑New Pum V-Pump Replacement ❑Pump Repair D Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method ❑Mud Rotary D Air Rotary D Auger ❑Cable Tool ❑Push Point D Other <br /> Proposed Well Depth 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 Schad D Steel ❑Plastic ❑Stainless Steel ❑Other <br /> Grout Seal Depth ft ❑Neat Cement(94 lb bag/5-10 gal water) D Sand Cement sack mixll gal water <br /> ❑Bentonite(20%solids) ❑Other <br /> Grout Placement Method ❑Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑ Other <br /> ❑Concrete Pedestal❑Dimensions:Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe <br /> PUMP Submersibleo Turbine D Other HP Pump Set ft 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 CO E ATION AWS <br /> MI R CE NOTICE REQUIRED FOR I�ECTIONS-PLEASE CALL(209)95 6 A <br /> SIGNED TITLE—��/ e!/r DATE <br /> I It <br /> T <br /> D <br /> a <br /> U 7, <br /> YI <br /> ILI If, T <br /> 81PA.RTMENT USI ONLY Q <br /> Application Accepted By Date Area 6 Employee ID#A / <br /> `l <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection By t Date g Z ' ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received C Amount ate Permit/ Invoice# Well ID# <br /> Codes Info B a h Remitted Service Re uest# <br /> 1 0$OU 00- 7 <br /> EHD 43-06 6/11/2019 WELL/PUMP PERMIT <br />