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WELLIPUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAIELTON AVENUE-STOCKTON CA 95205-(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 09 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESSCriY/LP <br /> flyA--5 _ <br /> a -��oo— X40 <br /> CROSS STREET APN PARCEL SIZE LAND USE APPLICATION III {vp <br /> OWNER NAME 1' PHONE Si <br /> OWNER ADDRESS ✓ `�ilt CITYISTATFIZIP <br /> CONTRACTORY <br /> �/ PHON(E�./� <br /> CONTRACTOR ADDRESS I 1 Cu CI Y/STATEIZ1P <br /> SUBCONTRACTOR PHONE V <br /> SUBCONTRACTOR ADDRESS Cr7YlSTATEMP <br /> LICENSE C-57 ❑C-61 O 0-09 0 Other NUMBER t <br /> �L EXPIRATION DATE <br /> DOMESTIC VVELLSAMPLING:0 General Mlneral/Coliform Bacteria(4391)0 Dibromochloropropane(4392)0 Arsenic(4393) <br /> INTENDED USE omesUcfPrivale ❑ ulgatioNAgricullurel O Industrial D Water quality Monitoring ❑Soll Sampling/Characlerizallon <br /> ❑Public Water System <br /> Ir dilferenlfmm Omer, Waler System Nunn Comsat Name or Phone Number I <br /> TYPE OF WORKNew Well 0 Replacement Well 0 Well Alleration/Modification ❑Other <br /> x❑Monitoring Well(s) #of wells ll Soil Boring(s) solborinp. ❑Geolechnlcal °rbOn"a• <br /> Cl Oul-OfService Well ❑Out-Of-Service Well Renewal 0 Cross-Connection Repair <br /> w 0 New PUM2 D Pump Replacement ❑Pump Re air ❑Raise Well Casing <br /> Drilling Method CONSTRUCTION Mud Rolerr'XX'`` ❑Air Rolery ❑Auger D Cable Tool D Push Point CIOther <br /> Proposed Well Depth S. ft Excavallon—)11--In diameter ❑Open Bottom O Gravel Pack/Gravel Slz In diameter <br /> ❑Conductor Casing In diameter / Conductor�Casing Depth ft <br /> Well Casing Diameter in, Thlckness/Gauge/ASTM Schad WO D Sleet Plastc 0 Sla I ss�leeI ❑Other <br /> Grout Seal Depth ft O Neat Cement(94 Ib bag�5-f0 gal water) Send Cement %f sack mixr7 gel water <br /> ❑Bentonite( %solids) ❑Other <br /> Grout Placement Method umped ❑Free Fell D Other O Retardant I Accelerator(name) <br /> PEDESTAL Installed By ❑Driller U Pump Contractor ❑ Other <br /> ❑Concrete Pedestal❑Dlmenslons:Width_ft Length ft Thick In ❑Christy Box ❑Stove Pipe <br /> PUMP ❑Submersible❑Turbine ❑Other HP Pump Set ft Standing Water Level R <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 1 AM IN COMPIJANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MINIMU E NOTICE REQUIRED EQCTJON -PLEASE CALL(209 3--37697 <br /> I <br /> SIGNED <br /> IIWNVI' DATE •� +{j <br /> 3 <br /> 7-1 <br /> Ts I 0 .I NL 1 ,` I <br /> pgYMF <br /> ------------------- <br /> REDE�VNT <br /> ED <br /> U� 0� 2020DA <br /> N <br /> 17DN�g ENTY� <br /> R TMENT <br /> DEPARTMENT USE,ONLY <br /> Application Accepted By y <br /> Z— Date / tX�n,3-b Area (� Employee ID# S'/< <br /> , <br /> Grout Inspection By Date ,X SPECIAL Well Permit <br /> Pump Inspection By Date X WAIVER Received <br /> Soil Boring Inspection By Dita Constructed Well Depth R <br /> COMME(TS fj�, t'r d _r If' <br /> _t IPI ttt IIeA'&S t` 9 IC Tt1T s F f11 c+h �f�1 1tr`/iA'., 1/%L'ffi IrJ( 112 ,tICs1J1�Ltln SlJ <br /> �l-l•��'�F ���� <br /> PE Sc Received Check#r Amount Data Permit/ invoice# Well IDS <br /> Codes Info B4-,) Cash Remitted Service Re uest# <br /> L3('F' 1 , SCS 41100 , t��rfF`,f�,lS <br /> WELL!PUMP PERMIT <br /> EHO X3-06 aNllia <br />