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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95,205-6232 (209)468-3420 <br /> NON-REFUNDABLE PERMIT www.sjgov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 6011 ic.D, CITY/ZIP ftDGt-71VN rn <br /> A �Q D <br /> CROSS STREET /h�6K /to APN 111-I0O'07G Df DOB PARCEL SIZE W AC LAND USE APPLICATION# A <br /> •- A ,/ m <br /> OWNER NAMEGK6L �(7TM7✓�1 PHONEN <br /> OWNER ADDRESS �7 1"'P^r W VQ CITY/STATE/ZIP LtJ JT H (./A" 91707 <br /> �E �� <br /> CONTRACTOR -44100 0vi &'W" !awrn-� IyL- PHONE 71 y 6 -So2r <br /> CONTRACTOR ADDRESS V7 N Ltt4+e.✓ S'r CITY/STATE/ZIP D�e/`af <br /> SUBCONTRACTOR/ ONSULI' &A-41144L��'K�`Ir- eQ.jSOG(rir�I PHONE I ItOY7? p <br /> SUBCONTRACTORICONSULTANT ADDRESS Oro 6kaw74o'4L­ mwp CITY/STATE/ZIP I vew F44±.A UP C/A- 7 1-6'(1 <br /> LICENSE '\ -57 LI C-61 I D-09 U Other NUMBER ys� EXPIRATION DATE <br /> BILLING PARTY: I OWNER i�CONTRACTOR /11Z;UBCONTRACTORVNSU <br /> DOMESTIC WELL SAMPLING:i I General Mineral/Coliform Bacteria(4391)!_1 Dibromochloropropane(4392), Arsenic(4393) <br /> INTENDED USE n Domestic/Private D Irrigation/Agricultural ❑ Industrial D Water Quality Monitoring kSoil Sampling/Characterization <br /> D Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK 11 New Well D Replacement Well D Well Alteration/Modification 'Other GPT x 9 <br /> D Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings ❑ Geotechnical #of borings <br /> 11 Out-Of-Service Well D Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> 11 New PUMP D Pump Replacement D Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method ❑ Mud Rotary ❑ Air Rotary D Auger D Cable Tool Push Point n Other <br /> Proposed Well Depth f-40 It Excavation y in diameter D Open Bottom D Gravel Pack/Gravel Size in diameter <br /> 0 Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_ in Thickness/Gauge/ASTM Sched D Steel D Plastic 11 Stainless Steel ❑ Other <br /> Grout Seal Depth__ ft KNeat Cement(94/b bag/5-10 gal water) 0 Sand Cement sack mix17 gal water <br /> U Bentonite(20%solids) D Other <br /> Grout Placement Method I i Pumped D Free Fall F}Other -M64416- D Retardant/Accelerator(name) <br /> ��7 <br /> Installed By ❑ Driller D Pump Contractor ❑ Other <br /> D Concrete Pedestal❑Dimensions:Width ft Length It Thick in D Christy Box D Stove Pipe <br /> PUMP D Submersible❑ Turbine D 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 1 AM IN COMPLIANCE. WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MIN 48 HOUR VANCE NOTICE REQUIRED FOR/INSPECTIONS - PLEASE CALL (209) 953-7697 <br /> SIGNED TITLE ✓ -- LC;,W'i-T DATE 00/2-0 <br /> T4 01 F 04h I <br /> Q <br /> T _ <br /> T <br /> DE ARTMENT/ U E O LY n <br /> Application Accepted By Date �` U Area 6 Employee ID# DQ((l C4.- <br /> Grout <br /> LGrout Inspection B DateTEZY SPECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Amount Date Permit/ Invoice# Well ID# <br /> Codes Info BY, Cash Remitted Service Re uest# <br /> S lZ wp(Tqj q t1 <br /> EHD 43.06 6/11/2019 WELL/PUMP PERMIT <br />