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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 Cn <br /> JOB ADDRESS Qn CITY/ZIP /ryi�C� Lir? m <br /> 7 <br /> CROSS STREE APN Z �5 PARCEL SIZED l LAND USE� � <br /> APPLICATION# �J p <br /> OWNER NAMEdo PHONEC�{(/ _'n(�3/J_//}5Z/ rV'i <br /> OWNER ADDRESS d, 611e101 I? CITY/STATE/ZIP g/5yyH4r A `7 /-Bj <br /> CONTRACTOR "7,_.l <br /> PHONE f�� (32[ <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP ( • q�`5 <br /> SUBCONTRACTOR/CONSULTANT A /�I PHONE ot� 144 <br /> SUBCONTRACTOR/CONSULTANT ADDRESS C /STATE/ZIP <br /> LICENSE 57 11 C-61 11D-09 F1 Other NUMBER EXPIRATION DATE�V/^� <br /> BILLING PA TY: OWNER CONTRACTOR SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE omestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/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 Ll Other <br /> ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings -; Geotechnical #of borings <br /> ❑ Out-Of-Service W II ❑ Out-Of-Service Well Renewal El Cross-Connection Repair <br /> 01 New Pum Pum 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 /> �i Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched 1-1 Steel L Plastic P Stainless Steel I Other <br /> Grout Seal Depth ft LI Neat Cement(94 Ib bag/5-10 gal water) i I Sand Cement sack mix/7 gal water <br /> ❑ Bentonite(20%solids) ❑ Other <br /> Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other I I Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller LI Pump Contractor ❑ Other <br /> I Concrete Pedestal❑Dimensions:Width ft Length ft Thick in Christy Box ❑ Stove Pipe <br /> PUMP Submersibleu 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 /> MINIMUM 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED TITLE DATE <br /> LBO <br /> A <br /> L7 N N <br /> R <br /> DEP RTMENT USE 7LY <br /> Application Accepted By V v U Date ZV Area ! I Employee ID# <br /> Grout Inspection By '''� Date ` r SPECIAL Well Permit <br /> Pump Inspection By ,(,,�p U_yn�,' V,�`L Date WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC ReceivedChec Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B Cash Remitted Service Request# <br /> '3 050 I.I� [ 003 7. a•l DUq 252:5 <br /> EHD43-06 6/11/2019 / /!. �71) liar•' 1-fj035 31)ye . WELL/PUMP PERMIT <br />