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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 /> JOB ADDRESS -713 L 5 FL D� -� D 51 CITY/ZIP �� I m <br /> i <br /> m <br /> CROSS STREET V`C 64--r, APN 193-676 -07 y Q q D <br /> PARCEL SIZE 3 l� LAND USE APPLICATION# �/+ �� 0 � � <br /> 0 <br /> J'A 2/✓�I L UyPHONE <br /> OWNER NAME ]� ®� <br /> OWNER ADDRESS �/ LI V li"�lf�I CITY/STATE/ZIP �T 1 P't <br /> CONTRACTOR �L' fiJ" PHONE <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> SUBCONTRACTOR/CONSULTANT PHONE <br /> SUBCONTRACTOR/CONSULTANT ADDRESS CITY/STATE/ZIP <br /> LICENSE C-57 C-61 _ D-09 _ Other NUMBER EXPIRATION DATE <br /> BILLING PARTY: _OWNER _CONTRACTOR SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391)i Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE Domestic/Private i_ Irrigation/Agricultural - Industrial _ Water Quality Monitoring _ Soil Sam piing/Characterization <br /> 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 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 Sched Steel Plastic Stainless Steel 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) 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 /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MINI R ADVANCE NOTICE REQUIRED FOR INSPECTIONS -PLEASE CALL (209) 953-7697 <br /> SIGNED \ TITLE DATE <br /> Au <br /> DEPARTMENT USE ONLY HFt y ON1NENT�N7y <br /> OEpA�� A�[_t <br /> Application Accepted By J Z 1_ Dateld .20'Zu Area i �� Employee IC7 FNFZ <br /> Grout Inspection By j� Date '7 E SPECIAL Well Permit <br /> Pump Inspection By CJ1/J81 J1,24.o-, Date 02_0 WAIVER Received <br /> I— r,_ <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS )pme-e Goocjl)ioi1 r-",-",- leytPf /ssu(,Cj on "), d7 dodo, �! 1-rWlA Lip 67 fwt*» WC,11 At-,-,,,-J cwd <br /> P1P�su;e Irl wk gnCl I%rilIlei f(Dh tf C4n2tP'Ve beck r/arJ 12-1eVe/It101l C'.,PY�L(� <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B 14Cash Remitted Service Request# <br /> 7 I -o F 7 �� 2WPM tt 10 6f <br /> EHD 43-06 6/13/2019 t I I���j�,I�� WELL/PUMP PERMIT <br />