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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 MM_.Sjg0v.org/ehd EXPIRES 'I YEAR FROM DATE ISSUED <br /> JOB ADDRESS / CITY/ZIP lil'7 ��QG m <br /> CROSS STREET APNyV�0' PARCEL SIZE D <br /> LAND USE APPLICATION# O <br /> OWNER NAME HONE��'(�/ _w" / rn <br /> c <br /> OWNER ADDRESS CITY/STATE/ZIP <br /> i <br /> CONTRACTOR L� PHONE <br /> CONTRACTOR ADDRESS o/(/ CITY/STATE/ZIP <br /> SUBCONTRACTOR/CONSULTANT PHONE '/ <br /> SUBCONTRACTOR/CONSULTANT ADDRESS //9 a� � C Y//S�6kme <br /> TATE/ZIP_ /,.J//V dZjh! <br /> LICENSE XC-57 ❑ C-61 ❑ D-09 ❑ Other NUMBER EXPIRATION DATE+ AY, <br /> BILLING PARTY: D OWNER ❑CONTRACTOR ❑ SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING:XI General Mineral/Coliform Bacteria (4391) Dibromochloropropane(4392) ❑ Arsenic(4393) <br /> If <br /> INTENDED USE Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ 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 ,New Well Replacement Well ❑ Well Alteration/Modification ❑ Other <br /> ❑ 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 /> ❑ New Pump ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method)(Mud Rota�rryy-� ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point [j Other <br /> Proposed Well Depth 300 ft Excavation r'r in diameter ❑ Open Bottom Gravel Pack/Gravel Size l'*&&diameter <br /> ❑ Conductor Casing —� in diameter ! CondI for 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 mix17 gal water <br /> Bentonite(20%solids) ❑ Other <br /> Grout Placement Method Pumped ❑ Free Fall ❑ Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller Pump Contractor ❑ Other <br /> ❑ Concrete Pedestal❑Dimensions:Width ft Length ft Thick in ❑ 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 /> CURREAND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORK RS COMPENSATION LAWS. <br /> MI1 UM DV NCE NOTICE REQUIRED FOR INSPECTNS! -PLEASE CALL(209) -769 <br /> SIGNED TITLE CPA- DATE <br /> C <br /> A � <br /> VI C <br /> r� DEPARTMENT USE ONLY �El3gRrML <br /> Application Accepted By �I�� G� Date �' ay .�Oo7l� Area y Employee I#NTD <br /> Grout Inspection By ��1..(. I��Z li ��-t'(,��i1/ DateZ�J '� ❑ SPECIAL Well Permit <br /> Pump Inspection By �rcln.i _�(g Cc_y.-e: jluI-L� Date �JAr t2' ❑ WAIVER Received <br /> Soil Boring In ection By Date Constructed W 11 Depth ft <br /> COMMENTS O S i O <br /> PE SC Received AmountDate Permit/ Invoice# Well ID# <br /> Codes Info B Cash Remitted Service Re uest# <br /> 43xo os) ►�a ato WUNIHO <br /> L1370 iS� Li 0�-FI <br /> L)3rj 11-15 q <br /> EHD 43-06 611112019 WELL/PUMP PERMIT <br />