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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 WWW.S OV.Or /ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> % U_1 <br /> Jos ADDRESS I CITY/ZJP <br /> D <br /> CROSS STREET APN c�6/0 9�a 3 PARCEL SIZE f LI I LAND USE APPLICATION# 7 A <br /> OWNER NAME �_i/m s/nia?jjod PHONE Z�D/�y�y��j,77— /5Y N <br /> OWNER ADDRESS 5143 C% l(�(t° 0a�- Pa( , CITY/STATE/ZIP 4 C�,J/r�J //6 {p /J� <br /> CONTRACTOR PHONE[CJ�'j��Jf�, Q11-3.2/JVD <br /> CONTRACTOR ADDRESS / CITYISTATE0P 9ftM 7-L 6 ��O J <br /> SUBCONTRACTOR/CONSULTANT /�'6 PHONE <br /> SUBCONTRACTOR/CONSULTANT ADDRESS CI IS 171 <br /> LICENSE57 C-61 -1D-09 ❑Other NUMBER EXPIRATION DATE <br /> BILLING PA t� i. OWNER o CONTRACTOR D SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING:a General Mineral/Coliform Bacteria(4391)-1 Dibromochloropropane(4392)❑Arsenic(4393) <br /> INTENDED USE Domestic/Private ❑Irrigation/Agricultural a Industrial o 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 a New Well Replacement Well Well Alteration/Modification i Other <br /> 11 Monitoring Well(s) #of wells J Soil Bodng(s) #of borings I Geotechnical #of borings <br /> ❑Out-Of-Service W I 11 Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> o New Pum I umR Replacement o Pump Repair o Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method _1 Mud Rotary Air Rotary El Auger o Cable Tool Push Point ❑ Other <br /> Proposed Well Depth ft Excavation in diameter _i 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 o Stainless Steel J Other <br /> Grout Seal Depth ft ❑Neat Cement(94 to bag/5-10 gal water) ❑Sand Cement sack mixn gal water <br /> Bentonite(20%solids) ❑Other <br /> Grout Placement Method o Pumped o Free Fall o Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑Driller o Pump Contractor c Other <br /> J Concrete Pedestal❑Dimensions:Width It Length ft Thick in J Christy Box D Stove Pipe <br /> PUMP Submersibleo Turbine F 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 /> WORK COMPENSATION LAWS. <br /> MI lu 4A,H CE OTICE REQUIRED FW INSPEC -PLEASE CALL(209),953 <br /> SIGNED TITL DATE <br /> pAYME�T <br /> FcE/VE� <br /> N 2 9 2020 <br /> gQUll y C <br /> DEPARTMENT USE ONLY h IRON 014 <br /> d� Jab Area C� Employee DA <br /> Application M NT <br /> Application Accepted By Date <br /> Grout Inspection By aa Date SPECIAL Well Permit <br /> Pump Inspection ByData J WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received I Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B Cash Remitted Service Request# <br /> 438 Oso 7 <br /> EHD43-06 6/112019 WELL/PUMP PERMIT <br />