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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232(209)4683420 <br /> NON-REFUNDABLE PERMIT WWW.SjqOV.Or /ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS VK +erYl., om w I Ger lk UA., CITY/ZIP 7 ru cV 953-Y7 <br /> D <br /> CROSS STREET V O P,04�o ry PkwyAPN 2ogc9$'o'f0 PARCEL SQE r 30 LAND USE APPLICATION# <br /> OWNER NAME ir IU 6is LP PHONE / J� V/�0 T y <br /> OWNER ADDRESS AZA St Cr1Y/STATE/ZIP OF I)V ,p� t„✓ v07 <br /> C� <br /> CONTRACTOR N PHONE Y / -l3 <br /> CONTRACTOR ADDRESScol //Arc.-4 A rdor� W #/O CITY/STATE/ZIP ? �� <br /> SUBCONTRACTOR/CONSULTAN fYt/ Dr4lill"�n(� C1`, PHONE 09) //_�00 <br /> SUBCONTRACTOR/CONSULTANT ADDRESS 1 3 3 U/M-l.f�-�rUt I Y LI CI Y/STATE/ZIP a �/q <br /> LICENSE tfi C-57 C-61 n D-09 -1 Other NUMBER IT0900 EXPIRATION DATE L <br /> BILLING PARTY: a OWNER CONTRACTOR -1 SUBCONTRACTOR/CONSULTANT^^ <br /> DOMESTIC WELL SAMPLING:D General Mineral/Coliform Bacteria(4391)❑Dibromochloropropane(4392)D Arsenic(4393) <br /> INTENDED USE 7 Domestic/Private ❑Irrigation/Agricultural C Industrial ❑Water Quality Monitoring 44F Soil Sampling/Characterization <br /> 7 Public Water System <br /> If different from Owner. 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 /> MonitoringWell(s) #of wells F SoilBoring(s) #of borings ItGeotechnical _#or borings <br /> Out-Of-Service Well L Out-Of-Service Well Renewal U Cross-Connection Repair <br /> New Pump D Pump Replacement D Pump Repair ❑Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method 7 Mud Rotary ❑Air Rotary Auger ❑Cable Tool 7 Push Point ❑ Other <br /> Proposed Well Depth S-30 ft Excavation In diameter C Open Bottom C Gravel Pack/Gravel Size In diameter <br /> 7 Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Dlameter_in Thickness/Gauge/ASTM Sched C Steel C Plastic 7 Stainless Steel ❑Other <br /> Grout Seal Depth S`'3 U ft 4 Neat Cement(94 lb bag/5-10 gal water) C Sand Cement sack mW7 gal water <br /> -1 BentonitQ(20%solids) n Other <br /> Grout Placement Method,�Pumped Free Fall Other 7 Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑Driller C Pump Contractor ❑ Other <br /> 7 Concrete Pedestal DDimensions:Width ft Length ft Thick in r Christy Box D Stove Pipe <br /> PUMP C Submersible[]Turbine C Other HP Pump Set ft Standing Water Level ft <br /> 1 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 /> MII'N�IMUMHHOvU"DVANCE NOTICE REQUIRED FOR MSP [TJ�ONS`PLEASE CALL(209)9 j3-7j697 <br /> PA <br /> SIGNED CJ�'I ./ //C TITLE fu L '/y, DATE <br /> IGO <br /> I ItIR9/v N C0 <br /> H DFpgRN At <br /> #1 <br /> 771 <br /> 171-1 <br /> DEPARTMENTY <br /> Application Accepted By Z�Z' Date 81212& 20 Area Sfell Employee ID# S <br /> Grout Inspection By Date ❑ SPEC L Well Permit <br /> Pump Inspection By //tt Date ❑ WAIVER Received <br /> Soil Boring Inspection By r`9Aj.3 U C1y'L.tc IASDate g�c Constructed Well Depth ft <br /> COMMENTS <br /> PE Sc Received Check#1 Amount Date Permit/ Invoice# Well ID# <br /> Codes Info Ca Remitted Service Request# <br /> 137d 130 7a <br /> EHD 43-08 6/1112018 /']�_ /' ������ � 1����� WELL/PUMP PERMIT <br />