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t�,. 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 OV Of /ehd i E PIRES I YEAR FROM DATE ISSUED <br /> \ (/ <br /> JOB ADDRESSIDN'tatCITY21P rt—I <br /> CROSS STREET '4 "" BOO AP�J V PARCEL SIZELANO USE APPLICATION# p <br /> OWNER NAME NCE <br /> -,Zta 61 iiy •I W `• PHONE <br /> OWNER ADDRESS nObo,, mvi <br /> CITY/STATE/ZIP <br /> CONTRACTOR C��SUbsU(rGCP�HjO\N,Ekg1(0Z61-_38 <br /> �N <br /> CONTRACTOR ADDRESS 1S1r) r4c'dIG L;�( CIN/STATEIZP CA, '7J7/ <br /> �V <br /> IP 26 <br /> SUBCONTRACTOR/CONSULTANT _ PHONE <br /> SUBCONTRACTOR/CONSULTANT ADDRESS CIN/STATE21P <br /> LICENSE Q'657 ❑C-61 D D-09 ❑Other _ NUMBERG542tV-1 EXPIRATION DATE )20.— <br /> BILLING PARTY: ❑OWNER QeONTRACTOR ❑ SUBCONTRACTORICONSULTANT �TTT <br /> DOMESTIC WELL SAMPLING:❑General Mineral/Coliform Bacteria(4391)a Dibromochloropropane(4392)❑Arsenic(4393) <br /> INTENDED USE ❑DomesWPrivate ❑Irrigation/Agricultural D Industrial ❑Water Quality Monitoring %5119oliSampling/Characterization <br /> ❑Public Water System <br /> Rdirferentfrum Omer. Water System Name Contact Name or Phone Number <br /> TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Afteration/Modification 0 Other �. <br /> ❑Monitoring Well(s) #of wells - 7oil Boring(s)_r •ofborings QrGeotechnica: _*of borings <br /> ❑Out-OF-Service Well Dut-V-Service—u Renewal ❑Cross-Connection Repair <br /> ❑New Pump ❑Pump Replacement ❑Pump Repair ❑Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method 0 Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool mush Point ❑ Other G� <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 ❑Steel ❑Plastic ❑Stainless Steel D Other <br /> Grout Seal Depth Vh_ft Q Aeat Cement(94 lb bag/5-10 gal water) ❑Sand Cement sack mixl7 gal water <br /> ❑Bentonite(20%solids) ❑Other <br /> Grout Placement Method DPumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑ Other <br /> ❑Concrete Pedestal❑Dimensions:Width ft Length ft Thick in D Christy Box ❑Stove Pipe <br /> PUMP ❑Submersible❑Turbine ❑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 COMPENSATION LAWS. <br /> MINIMJR ADVANCE NCTTJCE REQUIRED FOR INSPEC IONS-PLEASE CALL(209^))953-769777 <br /> SIGNED c _ TITLE DATE <br /> DATE Z U <br /> FNT <br /> -41 <br /> FO <br /> ?0 <br /> c <br /> p Nry <br /> r <br /> "RTMENT U E O LY <br /> Application Accepted By Date Areaployee ID# <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection By .( Date ❑ WAIVER Received <br /> Soil Boring Inspection By T(�fM(;S(a �, ;p Date Constructed Well Depth ft <br /> COMMENTS <br /> PE Sc Received Amount t Perm1U Invoice# Well ID1r <br /> Co Info Cash Remftt d Service Re uest# <br /> y 2 <br /> EHD 4306 6/112019 WELL/PUMP PERMIT <br />