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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 .S ov.OT /ehd MPIRES I YEAR FROM WTE ISSUED <br /> L <br /> JOB ADDRESS tt�-�f�G CITYZP ML <br /> CROSS STREET PN O V vy PARCELSIZE �� 6 LAND USE APPLICATION# o <br /> m <br /> ONRIER NAME PHON /L N <br /> CIIIMIER ADDRESS CITYISTATEZpfPHO <br /> r�N��gy <br /> CONTRACTOR — PHONE <br /> � /E 1�"b <br /> CoNmcTDR ADORES CITY/STATEMP ft LV//yy�-(" 7 <br /> StBCONTRACTORICONSULTANTPHON <br /> SUBCONTRAC�T/9RICONSULTANT ADDRESS ��xa/n,p <br /> LICENSE r G 57 C-61 D-09 Other NUMBER Mat V EXPIRATION DATE <br /> BILLING PAR E/vV OWNER CONTRACTOR SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL S PLING:',General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE X Domestic/Private Irrigation/Agricultural Industrial 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 New Well I Replacement Well Well Alteration/Modification Other <br /> MonitoringWell(s) #of wells SoilBoring(s) #ofbodngs Geotechnical #olbonngs <br /> Out-Of-Senn ll Out-Of-Service Well Renewal :Cross-Connection Repair <br /> I New Pump )<Pump Replacement Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary Air Rotary , Auger Cable Tool Push Point 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 Sched Steel Plastic I Stainless Steel ,Other <br /> Grout Seal Depth ft Neat Cement(94 Ib bag/5-10 gal watei) Sand Cement sack m&/7 gal water <br /> Bentonite(2n%cAids) Other <br /> Grout Placement Meth( i Free Fall , Other Retardant/Accelerator(name) <br /> PEDESTAL Installed liy Driller iPump Contractor i 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 1 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 UCENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMNS TION LAWS. <br /> MINI R A NOTIC,EE REQUIRED FOR II'�WEC�TIIJONSS-PLEASE CALL(209)95),769 <br /> SIGNED /�` TITLE / %�` DATE <br /> Li <br /> ECSENT <br /> EIVED <br /> UIV 0 5 2020 <br /> SA N � <br /> ROQUIN COU <br /> NMENTANTM <br /> H DEPARTMENT <br /> EP RT ENT SE ONLY <br /> Application Accepted By L� Date 5 a�O�`� Area l v/ I Employee ID# I <br /> Grout Inspection By Date I SPECIAL Well Pennit <br /> Pump Inspection By 1,cwW J to kQK>�hA,�L_ Date (a�2���slti i WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#( Amount Permit/ <br /> Codes Into Bu Cash Remitted atO Service Reauest# Invoice# Wcll ID# <br /> l o'0 I 7 <br /> EH043-08 6/11/2010 WELL(PUMP PERMIT <br />