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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 LaNu CITY/ZIP 60- L16DI r�ii <br /> 7 `�} '9 r D <br /> CROSS STREET APN AP[ +/�/Q "V PARCEL SIZIF , LAND USE AAPPPPL[I/ICC�ATION# I �X-y(/�� 0 <br /> OWNER NAME PHONE ry} l►'01 U U) <br /> U) <br /> OWNER ADDRESS < CITY/STATE/ZIP C <br /> _ryCONTRACTORow" HONE /`��( n�, �t7�I <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP oftmtn: <br /> SUBCONTRACTOR/CONSULTANT PHONE <br /> SUBCONTRACTOR/CONSULTANT ADDRESS ITY/STATE/ZIP <br /> LICENSEC-57 Ll C-61 Li D-09 ❑ Other NUMBER EXPIRATION DATE <br /> BILLING PA TY: OWNER CONTRACTOR SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE 11 Domestic/Private Irrigation/Agricultural CI Industrial ❑ Water Quality Monitoring C Soil Sampling/Characterization <br /> 1 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 ❑ u ❑ Air Rotary ❑ Auger ❑ Cable Tool I i Push Point 7 Other <br /> Proposed Well Depth ft in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel Size in diameter <br /> ❑ Conductor Casing in diameter / or Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched teel C1 Plastic ❑ Stainless Steel ❑ Other <br /> Grout Seal Depth ft ❑ Neat Cement(94 Ib bag/5-10 gal water) ement sack mix/7 gal water <br /> ❑ Bentonite(20%solids) ❑ Other <br /> Grout Placement Method I I Pumped ❑ Free Fall ❑ Other i Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller ❑ er <br /> ❑ s a ❑Dimensions:Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe <br /> PUMP ❑ Submersible Turbine ❑ Other HP Pump Set LL D ft Standing Water Level_Z_gy 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 /> WORK E COMPENSATION L S. <br /> �MI UM 4A E NOTICE REQUIRED F INSPE TIONS-PLEASE CALL(209)953-7697 <br /> SIGNED TITLE 0,1ADATE <br /> `QIF— <br /> I'C� <br /> L. , <br /> � C <br /> 1� <br /> A <br /> UAIA— <br /> N E <br /> EP RTMENT SE ONL3ww) <br /> Application Accepted By / Date /'�;O-ay <br /> W Area Employee ID# <br /> Grout Inspection By n Date PECIAL Well Permit <br /> Pump Inspection By jaj Lis Li, vczln c + Date 711 q&12Z_O WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE Sc Received (LqecW Amount PermiU <br /> Codes Info B Cash emitted Dat Service Request# Invoice# Well ID# <br /> D ' <br /> EHD43-06 6/11/2019 WELL/PUMP PERMIT <br />