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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 EXPIRES 1 YEAR FROM DATE ISSUED <br /> Joe ADDRESS 7I O O w_ T I�AAJ y c A 0 CrrY/ZIP it AS-4 C.,At <br /> G,w // �C`7�r�Yn�fir. pq l D <br /> CROSS STREET r, iG d APN Z 0 I 0 2-O PARCEL SIZE l'p LAND USE <br /> 'fAP-P�LIICATK)N# A <br /> OWNER NAME I1 A+\ 1 T��� Q -2 PHONE LU\ �ci�5 <br /> OWNER ADDRESS 1'71^0 e c'w' Z I 111 An^r 1� AA CRY/STATE/ZIP Tf At.� C-pA �t 1 S3 S I <br /> CONTRACTOR &4NjA4�c.0 DO,, <br /> �r1Vlf0n��/���7 �n-�. PHONE'?-(" \ TIP 7'/0. <br /> CONTRACTOR ADDRESS S1-7 >N A, A OA AO CRY/STATEMP J—10 C-K / 0,-,1 <br /> S A0 <br /> SUBCONTRACTORICONSULTANT A1`�l A-S t) V e PHONE f 1 r r <br /> SUBCONTRACTOR/CONSULTANT ADDRESS 1 1 1 r CITY/STATEMP I I I I / <br /> LICENSE -AIC-57 C-61 D-09 Other NUMBER 00 Z r-l EXPIRATION DATE-1 I 3 O O z I <br /> BILLING PARTY: OWNER ONTRACTOR SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392):.:Arsenic(4393) <br /> INTENDED USE 'Domestic/Private -.Irrigation/Agricultural Industrial Water Quality Monitoring Soil Sampling/Characterization <br /> Public Water System <br /> If different from Owner. Water System Name Contact Nam w Phone Number <br /> TYPE OF WORK New Well Replacement Well Well Alteration/Modification Other <br /> Monitoring Wells) #of wells Soil Boring(S) n of bongs ?%yGeotechnicai of bo"al's <br /> Out-Of-Service Well Out-Of-Service Well Renewal Crass-Connection Repair <br /> New Pum Pump Replacement Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary Air Rotary -(<,Auger Cable Tool Push Point Other N �� <br /> Proposed Well Depth 14 A it Excavation 1-J I-It in diameter Open Bottom Gravel Pack/Gravel Size NIA in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Schad Steel :Plastic -1 Stainless Steel Other <br /> Grout Seal Depth 15 It Meat Cement(94 lb bag/5-10 gal wafer) Sand Cement sack mix/7 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method umped - 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 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 CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MINIMUM 48 H R A,/AN NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> C� A A, GCr DATE )Z-) J ZO( <br /> SIGNED <br /> TITLE �"'�Ori�+t <br /> MFT <br /> VE4 <br /> I It'd <br /> 2019 <br /> c <br /> NT UN�' <br /> TMFNt <br /> _ C DEPARTMENT USS 0 LY Permit / /] <br /> Application Accepted By _....Date 1 Area4� PECI&ll <br /> Employee 14 %4?1 <br /> �7 <br /> Grout Inspection By Date <br /> Pump Inspection By If at 1 WAIVER Received <br /> Soil Boring Inspection By Date r / Yf / !J"(^'_ Constructed Well Depth ft <br /> COMMENTS <br /> PE Sc Received 11Chec Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B sh Remitted Service Request# <br /> C' <br /> EHD 4306 6/11/2019 WELL(PUMP PERMIT <br /> T <br />