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JA,�to r1/1 <br /> WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232 (209)468-3420 <br /> NON-REFUNDAB E PERMIT -www.sjgov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS Cl e VIZ <br /> Im t-11 CITQI> CGS 06 y?12 V m <br /> CROSS STREET (e Jew�r 14 D <br /> /� (�n AP(�N r,��} p VolPARCEL SIZE LAND U JE A(P�PLICCATI N# 1 <br /> OWNER NAME e Av `" / -J i 1 ` v PH E`" �J � ` -F <br /> m <br /> OWNER ADDRESS �I C' CITY/STATE/ZI C, I tJ CJ �J <br /> CONTRACTOR � <br /> G� //� I PHONE J��G��j� " <br /> CONTRACTOR ADDRESS ` (/1 [ CITY/STATE IP� o ` ✓ � I� <br /> SUBCONTRACTOR/CONSULTANT / PHONE / A C^ <br /> SUBCONTRACTOR/CONSYj <br /> /NT ADDRESS /}�E CITY/SlTAATE/ZIIP Nn _ < <br /> LICENSE _ C-57 C-61 _ D-09 ! Other 2—I NUMBER W �!/ v EXPIRATION DATE ' U <br /> BILLING PARTY: -OWNER OX CONTRACTOR 7 SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELLS MPLING: ❑General Mineral/Coliform Bacteria(4391) = Dibromochloropropane(4392)C 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 Name or Phone Number <br /> TYPE OF WORK _ New Well L1 Replacement Well U Well Alteration/Modification Other <br /> - Monitoring Well(s) #of wells rl Soil Boring(s) #of borings - Geotechnical #of borings v1 <br /> Out-Of-Service W II U Out-Of-Service Well Renewal a Cross-Connection Repair <br /> - New Pum Pump Replacement ❑ Pump Repair C.Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method _ Mud Rotary a Air Rotary a Auger _ Cable Tool L Push Point _ Other v <br /> Proposed Well Depth ft Excavation in diameter _j Open Bottom L Gravel Pack/Gravel Size in diameter <br /> _ Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_ in Thickness/Gauge/ASTM Sched i Steel a Plastic _ Stainless Steel U Other <br /> Grout Seal Depth ft n Neat Cement(94 lb bagl5-10 gal water) Sand Cement sack mix17 gal water <br /> - Bentonite(20%solids) ❑ Other <br /> Grout Placement Method - Pumped 51 Free Fall I, Other • Retardant/Accelerator(name) <br /> PEDESTAL Installed By - Driller ❑ Pump Contractor Other W <br /> Concrete Pedestal LDimensions:Width ft Lenth ft Thick in _ Christy Box a Stove Pipe <br /> PUMP XSubmersible- Turbine n Other HP Pump Set ft Standing Water Level ft C <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY O INANCES, STATE LAWS, AND RULES AND REGULATIONS.`1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND AC V WITH TH,E CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERSCOM ION LA <br /> MINIMU H RA DVANCE NOTICE REQUIRED FO INSPECTIIONr/1S11/-�PLEASE CALL (209) 953-76 7 <br /> SIGNED TITLE IX ryl ce ! '""r 1 DATE Gof 1117 <br /> a, <br /> R 0 <br /> P L <br /> N <br /> tit <br /> DEPARTMENT USE ONLY <br /> G <br /> Application Accepted By �� — �J Date 6 d S-aTOdo Area y 1 Employee ID# 5 <br /> Grout Inspection ByII Date ❑ SPECIAL Well Permit <br /> Pump Inspection By �;rc__tnc. ;tom lQ34^ - � V'L Date �����`Z¢ ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE Sc Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B Remitted Service Re uest# <br /> N38 Oso a >7 po-l0 p11)- <br /> EHD 43-06 6/1112019 WELL/PUMP PERMIT <br />