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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.Sgov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS n� -` ` t CITY/ZIP % m <br /> CROSS STREETC/`C41Z �` APN 4/-050 '_-�LPARCEL SIZE �`_LAND USE <br /> �APPLICATION <br /> '}# -7 <br /> OWNER NAME _ �/" jr�^C/Y✓t L' I //�' / PHONE LLfT � V 4 /L <br /> OWNER ADDRESS 1 �•` •�^ CITY/STATT-/E//Z—IP <br /> - -- zs- <br /> CONTRACTOR <br /> Z G ft✓7 -_ PHONE <br /> CONTRACTOR ADDRESS `7 CITYIS-TATE/ZIP ./z, y►�g4L'/� <br /> SUBCONTRACTOR/CONSULTANT--1 -CJI��i S_ /1.,�rt PHONE Z�-•�` Z, <br /> SUBCONTRACTOR/CONSULTANT ADDRESS CITY/STATE/ZIP <br /> LICENSE 'Acte-5757 rl C-61 ❑ D-09 ❑ Other NUMBER 4 73btEXPIRATION DATE_ <br /> BILLING PARTY: OWNER 1 CONTRACTOR SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE omestic/Private ❑ Irrigation/Agricultural ❑ Industrial Cl 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 Xlew Well ❑ Replacement Well • U Well Alteration/Modification ❑ Other <br /> F1 Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings ❑ Geotechnical_ #of borings <br /> ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal D Cross-Connection Repair <br /> >4ew Pump ❑ Pump Replacement ❑ PUInp Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method l04ud Rotary D Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point 11 Other _ <br /> Proposed Well Depth,3 00 ft Excavation � in diameter ❑ Open Bottom Gravel Pack/Gravel Size- in diameter <br /> ❑ Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter 6 in Thickness/Gauge/ASTM Sched Z ZD D Steel Mastic ❑ Stal less Steel ❑ Other <br /> 1 <br /> Grout Seal Depth _ D It ❑ Neat Cement(94 Ib bag/5-10 gal water) and Cement /0• sack mix17 gal water <br /> ❑ Bentonite(20%solids) ❑ Other <br /> Grout Placement Method 04umped ❑ Free Fall D Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By D Driller ❑ Pump Contractor ❑ Other <br /> ❑ Concrete Pedestal❑Dimensions:Width_1�'_it Length Q It Thick in ❑ Christy Box ❑ Stove Pipe <br /> �PuMP >WeSubmersibleo Turbine 1 i Other HP " Pump Set it 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 /> MINIMUM 48 HOUR A ANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED �t�[ s TITLE Vt Ji'- DATE�L' `7- J <br /> 44 <br /> Aq <br /> - Q <br /> J_ IVY <br /> EPARTMENT U E ONLY nn <br /> Application Accepted By Date 12 ( Area Employee ID# 1� <br /> Grout Inspection By Date a SPECIAL Well Permit <br /> Pump Inspection By 4 <br /> �(f,rNr d Vuw� Date I n� >A16 WAIVER Received <br /> 4� � �¢ `�I <br /> Soil Boring Inspection By Date Constructed Well Depth 3� ft <br /> COMMENTS !GC \\O� j�W SWQf�_ (nq,,�. - <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes I o By Cash Remitted Service Request# <br /> 14 fit] bio Q <br /> rL <br /> EHD 43-06 6/11/2019 WELL/PUMP PERMIT <br />