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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-REFUNDAB PERMIT www.Noy.org/ehd IRE S 1 YEAR FRqWV D LIED <br /> _m <br /> JOB ADDRESS Q Ka CITY/ZIP[, r-Ir <br /> CROSS STREET APN O4 71�O 1 9'v D <br /> PARCEL SIZE LAND USE A/PMPHLICAT�IjO�N#/�1L o <br /> �-/-11IL�`�ko m <br /> OWNER NAME12, HON m <br /> OWNER ADDRESS CITYISTATEIZIP <br /> CONTRACTOR �(\��J� ONPHHJOINE 22 -� da/D <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP W V[..I&l/ X4 q-5D454 <br /> SUBCONTRACTOR/CONSULTANTAt lot ✓ PHONE irN 414 <br /> SUBCONTRACTORICONSULTANT ADDRESS CIjj1,'IS((T��JrT�E/21(/Pn <br /> LICENSE XC-57 ❑C-61 D D-09 ❑Other NUMBER � EXPIRATION DATE <br /> BILLING PARTY: ❑OWNER ❑CONTRACTOR ❑SUBCONTRACTORICONSULTANT <br /> DOMESTIC WELL SAMPLING:D General Mineral/Coliform Bacteria(4391)D Dibromochloropropane(4392)❑Arsenic(4393) <br /> INTENDED USE omestic/Private 0 Irrigation/Agricultural D Industrial ❑Water Quality Monitoring 0 Soil Sampling/Characterization <br /> 0 Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK 0 New Well Cl Replacement Well 0 Well Alteration/Modification ❑Other <br /> 0 Monitoring Well(s) #of wells ❑Soil Boring(s) #of borings ❑Geotechnical #of borings <br /> ❑Out-Of-Service ell ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> ❑New Pum Pum Replacement D Pum Repair 11Raise 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 Schad D Steel ❑Plastic ❑Stainless Steel 0 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) 0 Other <br /> Grout Placement Method 0 Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑Driller 0 Pump Contractor ❑ Other <br /> ❑Concrete Pedestal❑Dimensions:Width ft Length ft Thick in D Christy Box ❑Stove Pipe <br /> PUMP Submersible❑Turbine ❑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 COMPEN ATION LAW <br /> MINI U E NOTICE REQUIRED FOR I /PPEC✓TTIIONNS-PLEASE CALL(209 76 7 <br /> SIGNED TITLE //,y;%?G� l DATE / <br /> -41 <br /> �®VAC <br /> 1® 020 <br /> CAAA <br /> J-4 MCFN �N>Y <br /> EPA TMENT USE ONLY (� 711 <br /> Application Accepted By ate 3 �O ZO Z Area1 Employee ID#�� /`�. •u <br /> Grout Inspection By Date ❑Well Permit <br /> Pump Inspection By Z <br /> rt Date �a ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE Sc Received eck#/ Amount Date Permi <br /> t/ invoice# Well ID# <br /> Codes Info B Remitted Service Re uest# <br /> 13s1 0..;70 1 <br /> EHD43-DB 6/11/1019 WELL/PUMP PERMIT <br />