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16 fid <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 y1 /1 Www.S ov.or /ehd �/1IEXPIRES 'I YEAR FROM DATE ISSUED <br /> JOB ADDRESS <br /> Z�Z10 �'ll�n t "v' CITY/ZIP I q�7 / ! m <br /> C4,11( 0 r1 v <br /> CROSS STREET J> APN a�t�1� PARCEL SIZE 56•S�LAND USE APPLIIC�ATION# A <br /> C �L C411 C41 Tu S 0 PHONE Uq "I 7 0-1 v� <br /> OWNER NAME / l Q�/� j� ! '] <br /> OWNER ADDRESS `'�`I7���hn�/ J "" CITY/ TATE/ZIP rC4 1/-2 / -7 <br /> CONTRACTORlvv/ V( PHONE 7jcl -a& <br /> CONTRACTOR ADDRESS 'V ` � I/� I L1 '`'� CITY/STAT P �G A4 J�v VJ <br /> SUBCONTRACTOR/CONSULTANT N ) /{'�JPHONE l V I <br /> SUBCONTRACTOR/CONSULT T All / CITY/STATE/ZI /' " J `� <br /> -61 D-09 DEXPIRATION DATE' <br /> LICENSE C-57 a <br /> BILLING PARTY: OWNER CONTRACTOR 1 SUBCONTRACTOR/CONSULTANT '9 <br /> DOMESTIC WELL SAMPLING: ❑General Mineral/Coliform Bacteria (4391) - Dibromochloropropane (4392)❑ Arsenic(4393) <br /> INTENDED USE Domestic/Private U 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 U Replacement Well U Well Alteration/Modification _I Other <br /> Monitoring Well(s) #of wells r1 Soil Boring #of borings s) - Geotechnical #of borings Q <br /> U U — <br /> Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair- rut(/_7 r-- w7,P Km to <br /> New Pum U Pump Replacement ❑ Pump Repair C Raise Well Casin <br /> WELL CONSTRUCTION <br /> Drilling Method _ Mud Rotary U Air Rotary U Auger _ Cable Tool L Push Point _ Other <br /> Proposed Well Depth ft Excavation in diameter -i Open Bottom L Gravel Pack/Gravel Size in diameter <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 lb bag/5-10 gal water) n Sand Cement sack mix/7 gal water g5 <br /> Bentonite(20%solids) :1 Other <br /> Grout Placement Method - Pumped n Free Fall ❑ Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By - DrillerPump Contractor f= Other <br /> Concrete Pedestal LID m nsions:Width ft Length ft Thick in _ Christy Box U Stove Pipe W <br /> PUMPx Submersible- Turbine n 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 C_gMP� SATION LAWS. <br /> NIMU 48 HOU A E NOTI REQUI D FOR fS^ V P'E/CITIONS -PLEASE CALL (209) 51-76. Z <br /> C 1 <br /> vi <br /> SIGNED '�G� TITLE l 0 rn ct6 DATE 6 <br /> 1 <br /> i <br /> r4-1 Ili ILDI <br /> V' <br /> A <br /> -7l DEPARTMENT USE ONLY <br /> Application Accepted By 1�1 Date (-/,,7$ o�O,i�0 Area J 4U Employee ID# SK <br /> Grout Inspection By Date ( ❑ SPECIAL Well Permit <br /> Pump Inspection By F%rG7t_a Cw't c" Q�►-.: Date 05 ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE Sc Received G;oAmount Date Permit/ Invoice# Well ID# <br /> Codes Info B Cash Remitted Service Request# <br /> W3Sa osI 4 iso 17nmo <br /> EHD 43-06 6/11/2019 WELL/PUMP PERMIT <br />