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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA95205-6232(209)468-3420 <br /> NON-REFUNDABLE PERMIT r WWW.sjgov org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS _ S�/�/ 3Q'1/� / r +�71,�I rk CITY/ZIP TY-14Vy I J 3? 6�DD <br /> CROSS STREET PI r�G I t APN l/-1 1`'V ,D PARCEL SIZE L LAND USE APPLICATION# A <br /> OWNER NAME t(��1 �010 ) �j LC�} PHONE <br /> p� /p <br /> OWNER ADDRESS i 6010 'Volt J 1 JV�I� �`�v CITY/STATE/ZIP >eIve'j lnioGy('O� Z? <br /> CONTRACTOR 1 u / P{1HyO�}NE 0�I Cf4f- I�3 qs <br /> CONTRACTOR ADDRESS L00 I` Of� Crry1STATE21P rwkf00 -CA IS `�V <br /> !1'- `G 00 <br /> SUBCONTRACTOR/CONSULTANT "j (T r I in LL✓/�' PHONE/ b / �C� CSV <br /> SUBCONTRACTOR/CONSULTANT ADDRESS 11133 ��GL(yli,yar �/ Crry/STATE/7JP Q r� G� ✓v Q_ <br /> LICENSE ,jC-57 r­C-61 n D-09 -i Other NUMBER1209L � EXPIRATION DATE O 2'vZ <br /> BILLING PARTY: ❑OWNER jCONTRACTOR 7 SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING:0 General Mineral/Coliform Bacteria(4391)❑Dibromochloropropane(4392)0 Arsenic(4393) <br /> INTENDED USE 7 Domestic/PriVate 0 Irrigation/Agricultural C Industrial 0 Water Quality Monitoring Sail Sampling/Characterization <br /> 7 Public Water System <br /> If different from Omer. Water System Name Contact Name or Phone Number <br /> TYPE OF WORK i New Well i i Replacement Well i Well Alteration/Modification i i Other <br /> n MonitoringWell(s) #of wells r SoilBoring(s) #of borings .,Geotechnical_#ofborings <br /> Out-Of-Service Well L Out-Of-Service Well Renewal u Cross-Connection Repair <br /> �]New Pum :1 Pump Replacement 0 Pump Repair 0 Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method 7 Mud Rotary 0 Air Rotary I/Auger 0 Cable Tool 71 Push Point ❑ Other <br /> Proposed Well Depth10'30 ft Excavation in diameter C Open Bottom C Gravel Pack/Gravel Size In diameter <br /> I Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter In Thlckness/Gauge/ASTM Sched C Steel C Plastic 7 Stainless Steel ❑Other <br /> Grout Seal Depth 10-30 ft j Neat Cement(94 Ib bao-10 gat water) C Sand Cement sack mixl7 gal water <br /> -1 Bentonite(20%solids) n Other <br /> Grout Placement Method WPumped n Free Fall -1 Other n Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑Driller C Pump Contractor ❑ Other <br /> -i Concrete Pedestal❑Dimensions:Width ft Length ft Thick in 0 Chrlsty 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 COMPENSATION LAWS. <br /> MI UMUU�M 48 HOU V NC OTICE REQUIRED FOR <br /> CIS�'IjS,PF�CZION -PLEASE CALL(209)953-7f97 <br /> SIGNED v v V TITLE SOW V'[L-[L ���j DATE <br /> 1lc�e/vp® <br /> 202, <br /> NVIR p(I/N CO[lN <br /> LTK pEPA� L <br /> J/> DEPARTMENW-75 <br /> ONLY �,/ <br /> Application Accepted By f Date O a0 Area 1 c Employee ID#� <br /> Grout Inspection By Date F] SPECIAL Well Permit <br /> Pump Inspection By 10 4 Date WAIVER Received <br /> Soil Boring Inspection By Date t yJConstructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info 13VA Cas Remitted Service Rea ue t# <br /> FS_C) 67,;2 <br /> EH043-e6 6111r1019 " I 2-74,/ 1Lj-7 WELL/PUMP PERMIT <br />