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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 /> I l N <br /> JOB ADDRESS �O `Y�t l(� CJ��l 4,je CITYZip�J.L K} tZ(� °152.I5 M <br /> CROSS STREET C� f fj r 1 i�rx APN 1 L 9 O 11 PARCEL SIZE '11,`!LAND USE APPLICATION# 1/ A <br /> OWNIERNAME l ck" O, �f[] '�Y+�� LLQ PHONE 4 o -cOOOI I�/i► !l�_, �! <br /> OWNERADDRESS I(1 ito� 1�! 1 IDw l�lC(1 C1fGl� CITY/STATE2IP �AdCy,+Qa <br /> Y1. CA -I5?_09 <br /> CONTRACTOR S S PHONE Sys -118 5 <br /> CONTRACTOR ADDRESS I CITY/STATE/ZIP M o cles-vo 95-35&' <br /> SUBCONTRACTORICONSULTANT PHONE <br /> SUBCONTRACTOR/CONSULTANT ADDRESS CITY/STATE/ZIP <br /> c �y <br /> LICENSE C-57 C 2-1! C-61 I i D-09 I Other NUMBER p0 )F) EXPIRATION DATE <br /> BILLING PARTY: L OWNER ONTRACTOR I I SUBCONTRACTORICONSULTANT <br /> DOMESTIC WELL SAMPLING:f General Mineral/Coliform Bacteria(4391)'Y, Dibromochloropropane(4392)❑ Arsenic(4393) <br /> INTENDED USEomestic/Private Irrigation/Agricultural 1-i Industrial I Water Quality Monitoring I I Soil Sampling/Characterization <br /> Public Water System <br /> If different from Owner. Water System Name Contact Name or Phone Number <br /> TYPE OF WORKlew Well 11 Replacement Well ❑ Well Alteration/Modification Other <br /> /`Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings LiGeotechnical #of borings <br /> Out-Of-Service Well ❑ Out-Of-Service Well Renewal Cross-Connection Repair <br /> New Pump Pump Replacement L Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method ,Mud Rotary Air Rotary L Auger Cable Tool Push Point ] Other <br /> Proposed Well Depth 2.1(o 0 ft Excavation _� in diameter i I Open Bottom Gravel Pack/Gravel Size 140 in diameter <br /> L Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter$ in Thickness/Gauge/ASTM Schad .jLiSteel Plastic ❑ Stainless Steel ❑ Other <br /> Grout Seal Depth ,IF © It i I Neat Cement(94 Ib bag/5-10 gal water) L Sand Cement sack mix/7 gal water <br /> Bentonite(20%solids) a Other <br /> Grout Placement Method XPumped Ll Free Fall r j Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By L Driller "Pump Contractor L Other <br /> Concrete Pedestal Dimensions:Width It Length ft Thick in L Christy Box ❑ Stove Pipe <br /> PUMP i1 Submersible-', Turbine i I 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 /> MINIMUM 48 HOUR ADVANCE NOTICE REQUIRED FO ` 'PECTIONS -PLEASE CALL (209) 953-7697 <br /> SIGNED LE �L • P. DATE +T " —2-0 <br /> S <br /> N <br /> � Fr <br /> � T <br /> DEPARTMENT USE ONLY F <br /> Application Accepted By �-- 1 Z_ Date 1 2.���0 Area / 7 Employee ID# <br /> Grout Inspection By /�Date 6 JA?-C-iO SPECIAL Well Permit <br /> Pump Inspection By Date 7 WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS EX/Stln4 We( is tots GiOSN to Y+?(1fC.1) , .51701 ibr <br /> PE SC Received heck#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B Remitted Service Re uest# <br /> 93°► I Sys10 <br /> 39d ;70 Ck' <br /> EHD 43-08 6/11/2019 WELL/PUMP PERMIT <br />