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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 96205-6232(209)4683420 <br /> NON-REFUNDABLE PERMIT <br /> /� e- www.S ov.or /ehd EXPIRES 1 YEAR FRo DATE ISSUED <br /> JOB ADDRESS l'�� ` L CITYIZIP D <br /> CROSS STREET C' AP7..11ZARCEL SIZE 7- )�ND USE APPLICATION# A <br /> OWNER NAME <br /> , ^ PHONE <br /> OWNERADDRESS w10 <br /> S CIT/STAEIP� /AK-it <br /> m <br /> 1 <br /> CONTRACTOR (,o�„[iX S. r /'�n� Q4,pl (G n /PHONE ! Z/� ^r Z�y5 <br /> CONTRACTOR ADDRESS I-:'10 Mad Pia lQ' I to CITY/STATEop I J iq t o C 4 "1 J IP GU <br /> SUBCONTRACTOR/CONSULTANT PHONE <br /> SUBCONTRAC <br /> -TO <br /> R/CONSULTANT ADDRESS CITYIISTATFOP <br /> LICENSE 57 ❑C-61 ❑0.09 ❑Other NUMBERGS42(0 1 E)mATION DATE <br /> BILLING PARTY: ❑OWNER QeONTRACTOR ❑SUBCONTRACTORICONSULTANT <br /> DOMESTIC WELL SAMPLING:❑General Mineral/Coliform Bacteria(4391)❑Dibromochioropropane(4392)0 Arsenic(4393) <br /> INTENDED USE ❑Domestfc/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring NWego)I Sampling/Characterization <br /> 0 Public Water System <br /> Ifdff mnt from Omer. Water System Name Contact Name or Phone Number <br /> TYPE OF WORK ❑New Well ❑Replacement Well ❑Well AHeratlon/Mod'Ification ❑Other <br /> ❑Monttoring Wells) #of wells .�6oil Boring #of borings s) QoGeatechnicai #of bodug� <br /> ❑Cut-Of-Service Well ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> ❑New Pump 0 Pump Replacement ❑Pump Repair 0 Raise Well Casing <br /> = CONSTRUM <br /> Drilling Method ❑Mud Rotary 0 Air Rotary ❑Auger ❑Cable Tool mush Point ❑ Other gkr <br /> Proposed Well Depth it Excavation in diameter 0 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 V_ft 0,Aeat Cement(94 lb bag15-10 gal water) ❑Sand Cement sack mix/7 gal water <br /> 0 Bentonite(20%solids) ❑Other <br /> Grout Placement Method L^mped ❑Free Fall 0 Other 0 Retardant/Accelerator(name) <br /> PEDESTAL Installed By 0 Driller 0 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 WX R ADV REQUIRED FOR INSPECTIONS-PLEASE CALL(209^))953-7697 <br /> SIGNED _ __ TITLEL_ ,,,�PSi DATE G_ <br /> CY�F <br /> T <br /> os?o?o <br /> O <br /> N <br /> C <br /> R� <br /> F�r <br /> : -151ARTMahl US O LY [� � <br /> Application Accepted By Date !nom(/// Area �' �`� Employee ID# <br /> Grout Inspection By Date i SPECIAL Well Permit <br /> Pump Inspection By 4 Date ❑ WAIVER Received <br /> Soil Boring Inspection By Date �Constructed Well Depth ft <br /> COMMENTS C,&-.e .'+ , /(�A.s( <br /> PE Sc Received Che. Amount D t Permh/ Invoice# WellID#' <br /> Codes Info em ed Service Ra uest# <br /> ti ° <br /> EHD 43-06 6/11/2019 WELL/PUMP PERMIT <br />