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s <br /> 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.sjgov.org/ehd EXPIRES 1 YEAR FROM PATE ISSUED <br /> JOB ADDRESS CITYMP m <br /> L (� D <br /> CROSS STREET APN v�/" � PARCEL SIZE�-3 LAND USE APPLICATION# A <br /> ' m <br /> OWNER NAME V PHONE �+ <br /> OWNER ADDRESS O CITY/STATEIZIP (�+ f_&f,,,^�yG�n�U <br /> CONTRACTOR C�o y'�U G7S U f (0 QZ DkrG N /'�PHONE-1)W�C,r/6 —3 O Z-7 <br /> CONTRACTOR ADDRESS I?)o rAAc PJG {d`/(1.16 <br /> CITY/STATEIZIP 1 J Iy� 64 `i J L,RZ <br /> SUBCONTRACTORICONSULTANT PHONE <br /> SUBCONTRACTORICONSULTANT ADDRESS CITY/STATE/ZIP <br /> YY <br /> LICENSE 457 ❑C-61 ❑D-09 ❑Other NUMBERG542(fl"1 EXPIRATION DATED'daa j210 <br /> BILLING PARTY: 11 OWNER iaeONTRACTOR ❑SUBCONTRACTORICONSULTANT <br /> DOMESTIC WELL SAMPLING:a General Mineral/Coliform Bacteria(4391)❑Dibromochloropropane(4392)O Arsenic(4393) <br /> INTENDED USE ❑Domestic/Private ❑Irrigation/Agricultural D Industrial ❑Water Quality Monitoring �LYSoPSampling/Cheracterization <br /> ❑Public Water System <br /> Hd'drerent from Omer: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Afteration/Modification ❑Other <br /> ❑Monftoring Well(s) #of wells .,0,6oIIBoring(s; Yofbodngs ,goGeotechnical_ iofborings <br /> ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> ❑New Pump ❑Pump Replacement ❑Pump Repair ❑Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method ❑Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool mush 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 Schad ❑Steel ❑Plastic ❑Stainless Steel ❑Other <br /> Grout Seal Depth 90 Q Xeat Cement(94 lb bag/5-10 gal water) ❑Sand Cement sack mix/7 gal water <br /> ❑Bentonite(20%solids) ❑Other <br /> Grout Placement Method QPumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑ Other <br /> ❑Concrete Pedestal❑Dimensions:Width_ft Length ftThick in ❑Christy Box ❑Stove Pipe <br /> PUMP ❑Submersible❑Turbine ❑Other HP Pump Set ft Standing Water Level ft <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 LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MINIM R ADV REQUIRED FOR IN/S�PEC IONS-PLEASE CALL(209)9633-7697 <br /> SIGNED = TITLE ��tC.Si DATE Z [t,I ZZ <br /> E Y�FNT <br /> SAA <br /> Pq�TMENT <br /> SDE TMENT USE ONLY <br /> Application Accepted By Date Area mployee ID# �� <br /> Grout Inspection By f Date SPECIAL Well Pef7T11t <br /> Pump Inspection By Dated 'WA ReCeiVed <br /> Soil Boring Insins act w Date ✓LI 1 t (�.� Congtru M�W�I�e ft <br /> COMMENTS 049 .0 M ��i = S C <br /> PE SC Received �� `.'�+ Amount Date Permit/ Invoice; We111DAf <br /> Codes Info ash Remftt Service Re uest# <br /> 0 <br /> EHD 43-06 61112019 WELL RUMP PERMIT <br />