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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.Or /ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS CITY/ZIP <br /> CROSS STREET APN 10 1 y PARCEL SIZE1-97 LAND USE APPLICATION##L^��/ <br /> OWNER NAME �PPHH,jO�NrE/,((�C/��71dO --&77 w <br /> OWNERADDRESS CITY/STATEMP6 V{/�C/I�n— �I �/5 <br /> CONTRACTOR cL_�PHHHO,O-,NE QfCJ_/��L N 0 <br /> CONTRACTOR ADDRESS CIN/STATE/ZIP 6'5 V L� <br /> SUBCONTRACTOR/CONSULTANT PHO <br /> SUBCONTRA7c-, <br /> CONSULTANT ADDRESS C /STAATEE,/ZIP �^/ <br /> LICENSE 57 ❑C-61 J D-09 ❑Other NUMBER � EXPIRATION DATE / .31—C�/ <br /> BILLING PARTY: E OWNER L CONTRACTOR C1 SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING:❑General Mineral/Coliform Bacteria(4391)G Dibromochloropropane(4392)❑Arsenic(4393) <br /> INTENDED USE Domestic/Private Fj Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring -1 Soil Sampling/Characterization <br /> fj Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK j New Well Replacement Well ❑Well Alteration/Modification ❑Other <br /> Monitoring Well(s) #of wells D Soil Bodng(s) #of borings n Geotechnical #of borings <br /> Out-Of-Service Well n Out-Of-Service Well Renewal J Cross-Connection Repair <br /> i New Pump P ump Replacement a Pump Repair -i Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method .I Mud Rotary Air Rotary ❑Auger ❑Cable Tool Push Point i i Other <br /> Proposed Well Depth ft Excavation in diameter i Open Bottom [I Gravel Pack/Gravel Size in diameter <br /> Ll Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Schad Steel Plastic r]Stainless Steel D Other <br /> Grout Seal Depth ft n Neat Cement(94 Ib bag/5-10 gal water) Sand Cement sack mixR gal water <br /> Bentonite(20%solids) n Other <br /> Grout Placement Method i_i Pumped ❑Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑Driller ❑Pump Contractor r' Other <br /> 11 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 ft <br /> , 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 CO E ATIO LAW <br /> MI UR E'N�OTIgCE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953- 697 <br /> SIGNED 1!!!/I%,{7�� TITLE�iEe2 JLG/� DATE T <br /> till <br /> NT <br /> d <br /> 0 <br /> t r <br /> DEPARTMENT USE ONLY <br /> Application Accepted ByGi�CDate s hF OZ-O Area g Employee ID# <br /> Grout Inspection By Date SPECIAL Well Permit <br /> Pump Inspection By�fa Iftpj:LIftrL%t Date WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received eck# Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B CB­5F Remitted Service Re nest# <br /> 438 LIS-0 YA R12011 477 <br /> EHD 43-05 8/112019 WELL/PUMP PERMIT <br />