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AcAU0 <br /> 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 A WWW.S OV.Of lehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS V GITYIZIPy, � m <br /> v' <br /> -7 D <br /> CROSS STREET n;,o �^S APN d O/I 33 1 PARCEL SIZE LAN USE APPLICATION# <br /> 24 b <br /> OWNER NAME PH NE <br /> OWNER ADDRESS S���� e I cru ` CITY/ A E/ZIP 'C/� '" � <br /> CONTRACTOR j , J C P vl �.L PHONE 1 J_oa v <br /> U � -roI/Q til C <br /> CONTRACTOR ADD n/ J CITY/STATEIZIP <br /> SUBCONTRACTOWCONSULTANT 11� PHONE <br /> SUBCONTRACTOR/CONSULTANT ADDRESS ITY/lE TA7E21P A <br /> LICENSE _ C-57C-til D-09 Other NUMBER O EXPIRATION DATE " <br /> BILLING PARTY: OWNER CONTRACTOR SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING: _.General Mineral/Coliform Bacteria (4391) = Dibromochloropropane (4392)L.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 a Replacement Well a 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 a Cross-Connection Repair 7t <br /> New Pump yPump Replacement Pump Repair = Raise Well Casin L—, <br /> I,,WELL CONSTRUCTION TA <br /> Drilling Method _ Mud Rotary a Air Rotary _ Auger _ Cable Tool L Push Point _ Other v� <br /> Proposed Well Depth ft Excavation in diameter ! Open Bottom L Gravel Pack/Gravel Size in diameter 9 <br /> - Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_ in Thickness/Gauge/ASTM Sched j Steel u Plastic _ Stainless Steel u Other <br /> Grout Seal Depth ft n Neat Cement(94 Ib bag/5-10 gal water) -1 Sand Cement sack mix17 gal water <br /> = Bentonite(20%solids) Other <br /> Grout Placement Method - Pumped 5- Free Fall 5 Other ^ Retardant/Accelerator(name) <br /> PEDESTAL Installed By = Driller E Pump Contractor Other <br /> _ Concrete Pedestal uDimensions:Width ft Length ft Thick in _ Christy Box u Stove Pipe <br /> PUMP Submersible- Turbine r1 Other HP Pump Set j LO I ft Standing Water Level i U11—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 LiCtidJE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS CO EN ATION LAWS. <br /> MIN 48 HOUR ADVANCE NOTICE REQUIRED FOR ILT ONSS -� PL ASE CALL (209913-76 7 r, <br /> SIGNED TITLE 771 <br /> Y { Ck' ,/` W� DATE <br /> 107, <br /> I <br /> S4Aj e_ <br /> I <br /> F <br /> Tly M AjU <br /> T <br /> I <br /> DEPARTMENT USE ONLY <br /> Application Accepted By _�� Date /d dodo Area 9C9 9 _ Employee ID# FR <br /> Grout Inspection By Date F_' SPECIAL Well Permit <br /> Pump Inspection By Date 4-(2M lyzv WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received eck Amount Permit/ <br /> Codes Info B as Date Remitted Service Re uest# Invoice# Well ID# <br /> q3$ 0so 7 IZ y0 <br /> EHD 43-06 6/11/2019 WELL/PUMP PERMIT <br />