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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.sjgov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> /Jq 9 ar 0 <br /> JOB ADDRESS CITY/ZIP l�! m <br /> /� I D <br /> CROSS STREET APN�"/ 1 PARCEL SIZE LAND USE APPLICATION# <br /> OWNER NAME / o A �PHjONEr(n <br /> OWNER ADDRESS ( � J��/rl%�//J Pd CITY/STATE/ZIP <br /> CONTRACTOR _ PHONE 3D/1-qj[6o_L10 <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP �(�� C// q5o S <br /> SUBCONTRACTOR/CONSULTANT At <br /> /^ PHONE /t`� /4 <br /> SUBCONTRACTOR/CONSULTANT ADDRESS /T/Y/STATE/ZIP <br /> LICENSE C-57 ❑ C-61 C D-09 ❑ Other NUMBER EXPIRATION DATE <br /> BILLING PARTY: OWNER CONTRACTOR SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE XDomestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring I-I Soil Sampling/Characterization <br /> I Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK ❑ New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other <br /> U Monitoring Well(s) #of wells !; Soil Boring(s) #of borings ❑ Geotechnical #of borings <br /> ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> I New Pump ❑ Pump Replacement 4pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method ❑ Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push 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 Sched ❑ Steel ❑ Plastic ❑ Stainless Steel ❑ Other <br /> Grout Seal Depth ft ❑ Neat Cement(94 Ib bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water <br /> ❑ Bentonite(20%solids) ❑ Other <br /> Grout Placement Method ❑ Pumped ❑ Free Fall I-1 Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By LI Driller ❑ Pump Contractor i Other <br /> ❑ Concrete Pedestal[]Dimensions:Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe <br /> PUMP Submersible❑ Turbine CI 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 /> WORKERS COMPENSATION LAWS. <br /> MUM DANCE NOTICE REQUIRED F R INSPE TIONS-PLEASE CALL(209) 95317697 <br /> SIGNED TITLE OPT�MDATE <br /> oh <br /> NY <br /> O <br /> / O <br /> E T <br /> N <br /> D PARTMENT <br /> USE ONLY <br /> L�i <br /> r 14 <br /> Application Accepted By ate Area Employee ID# <br /> Grout Inspection By Date PECIAL Well Permit <br /> Pump Inspection By f�ti'�to5(o ��trY c� '^ Date lG� I�Z�L✓ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Amount Date Permit/ Invoice# Well ID# <br /> COOPS Info B Cash Remitted Service Re uest# <br /> �0 3 <br /> EHD 43-06 6/11/2019 WELL/PUMP PERMIT <br />