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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 wvvvv.Bjgov.ora1ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> 452 <br /> wA S'tucwton `� <br /> JOB ADDRESS I"52ADO Gmga\`r r�Njq SNr.&1- CITYI7JP m <br /> 1 rq.,C D <br /> CROSSSTREET APN Ila^ZIP ��J PARCEL SIZ 11-Il 11�ND USE APPLICATION*L A <br /> OWNER NAME ` Y Q 2 1 ` PHHOON`E, !�! <br /> OWNER ADDRESS ] _ ` LLL— <br /> CITY/STATEIZIP�\—.,a-- `� � � , C/N <br /> `) <br /> CONTRACTOR \, xC C—�'E*=�Yt LSC Jrl \M PHONE <br /> CONTRACTOR ADDRESS 7�O R)OK_�y3 _ CITYISTATEIZIP <br /> SUBCONTRACTORICONSULTANT \ PHONE Iq <br /> - <br /> (,O- 1�Z'��OO_/ <br /> SUBCONTRACTORRICONSULTANTADDRESs�gL��'I�OCA:SC G CITYISTATFJZIPM WG "c7PGrR.M'1yc�Yl�'D lCJ4' 1 `�`� <br /> LICENSE IC-57 0 C-61 C D-09 O Other NUMBER t',a^ItP ExPIRATION DATE (O I.�.V lRO7U <br /> .BILLING PARTY: D OWNER D CONTRACTO�UBCONTRACTOR/CONSULTANT <br /> DomEsTic WELL SAMPLING:0 General Mineral/Coliform Bacteria(4391)0 Dibromochloropropene(4392)0 Arsenic(4393) <br /> INTENDED USE 0 Domestic/Private C Irrigation/Agricultural 0 Industrial 0 Water Quality Monitoring C Soil Sampling/Characterization <br /> 0 Public Water System <br /> If different from Owner. Water System Name Contact Name or Phone Number <br /> TYPE OF WORK C New Well 0 Replacement Well 0�Well Alteration/Modification D Other <br /> 0 Monitoring Well(s) #of wells G'Soil Boring(.)_ S_ k of bGdngs 0 Geotechnical k of borings <br /> 0 Out-Of-Service Well C Out-Of-Service Well Renewal 0 Cross-Connection Repair <br /> 0 New Pump 0 Pump Replacement 0 Pump Repair 0 Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method 0 Mud Rotary 0 Air Rotary /'Auger J Cable Tool ❑Push Point 0 Other <br /> Proposed Well Depth % fl Excavation_II In diameter 0 Open Bottom 0 Gravel Pack/Gravel Size in diameter <br /> 0 Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness�! uge/ASTM Schad 0 Steel 0 Plastic 0 Stainless Steel 0 Other <br /> Grout Seal Depth fl 'Neat Cement(94 Ib bag/5-f0 gal water) ❑Sand Cement sack mix17 gal water <br /> 0 Bentonite(20%solids) O Other <br /> Grout Placement Method 0 Pumped I-i/Free Fall O Other Retardant/Accelerator(name) , <br /> PEDESTAL Installed By C Driller 0 Pump Contractor ❑ Other <br /> 0 Concrete Pedestal ODimenstons:Width It Length ft Thick in 0 Christy Box C Stove Pipe <br /> PUMP D Submersible Turbine 0 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 I AM IN COMPLIANCE WITH ALL <br /> WORKERS C ENSATION LAWS. <br /> MINM8 HQUP APVANC� OT E REQUIRED FOR INSPECTIONS-PLEASE CALL(209)95?-7697 <br /> SIGNED _�f �L TITLE OI.IJw DATE 3 117 <br /> I <br /> i <br /> I i <br /> i <br /> 2020 <br /> R�FNT <br /> pEPARTMENT ;SE N-fLrY1 ''ll <br /> Application Accepted By Date^Zy�j� Area Employee ID# <br /> Grout Inspection By Date PECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Inspection By Date !''� Constructed Well Depth ft <br /> _ <br /> COMMENTS n)�f 5 j!, G 4 YXp, ,1�--�) c � — <br /> PE SC Received Amount Parm tU <br /> Codes Info 8 Cash ' Remitted Date Service R uGat# nvoice# Well ID# <br /> I <br /> EH043-M 9111/2018 WELL(PUMP PERMIT <br />