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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-FEFUNDABLE PERMIT Www.S OV.Or /ehd EXPIRES 'I YEAR FROM DATE ISSUED <br /> D <br /> JOB ADDRESS , -1 ✓• `� �T CITY/ZIP O akd0.�c q 53(o I m <br /> `' c Gy D <br /> CROSS STREET IJ• o-1i P l ea5 Q h�'V Qt�APN <br /> 2•2• -2 10 -2 `i PARCEL SIZE 1 O.3 LAND USE APPLICATION-#y p <br /> G 1 a _{1V- 1 G09 m <br /> OWNER NAME t\Q MQ� pal `� V PHONE <br /> OWNER ADDRESS ` Ay-fir-1 S y G O r lr 11 CITY/STATE/ZIP O CN,'<.a Q1G C A Q9 5 3(01 <br /> CONTRACTORthn l rd�S �1'0 �QQY f%A CO• T C• PHONE <br /> CONTRACTOR ADDRESS ' �JO La d J O !��• CITY/STATE/ZIP O C S . C Pt °►S 35� <br /> -�- <br /> SUBCONTRACTOR/CONSULTANT � PHONE <br /> SUBCONTRACTOORICONSULTANT ADDRESS CITYISTATE21P <br /> ` A 13 <br /> LICENSE }tom-57 C-61 D-09 Other NUMBER a EXPIRATION DATE 5 "3 7-O <br /> BILLING PARTY: OWNER %CONTRACTOR SUBCONTRACTOR/CONSULTANT <br /> 11 <br /> DOMESTIC WELL SAMPLING: I_ General Mineral/Coliform Bacteria(4391) _ Dibromochloropropane (4392)!- 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 WORKew Well Replacement Well Well Alteration/Modification Other <br /> N <br /> Monitoring Well(s) #of wells Soil Boring(s) #of borings Geotechnical #of borings <br /> Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair <br /> New Pump L Pump Replacement _ Pump Repair _ Raise Well Casin <br /> WELL CONSTRUCTION <br /> Drilling MethodxMud Rotary 1-1 Air Rotary Auger Cable Tool Push Point Other <br /> Proposed Well Depth_ 410 ft Excavation j q" in diameter Open Bottom Gravel Pack/Gravel Size I in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter$ in Thickness/Gauge/ASTM Sched 51)12?. L?. L _ Steel YPIastic ❑ Stainless Steel i Other <br /> Grout Seal Depth %nV ft -1 Neat Cement(94 Ib bag/5-10 gal water) [i Sand Cement sack mix/7 gal water <br /> )` Bentonite(20%solids) 1=I Other <br /> Grout Placement Method Pumped Free Fall I Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By - Driller Pump Contractor I_ Other <br /> LI Concrete Pedestal " Di enslons:Width ft Length ft Thick in Christy Box Stove Pipe <br /> PUMP D Submersible Turbine Other HP Pump Set ft Standing Water Level 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 LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> BINIMUM 48 HOUR ADVANCE NOTICE bIr <br /> QUI R\IN/SPECTIONS -PLEASE CALL (209) 953-7697 <br /> SIGNED TITLE Y P. DATE ICY 26,��� <br /> B <br /> � 0 <br /> i A <br /> DE A TMENMUS ON 1YApplication Accepted By n Date tC Area h Employee ID#Grout Inspection By` e. ' i Date ` ti 1 SPECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received`. j <br /> Soil Boring Inspection B Date Constr ted Well Depth l/ ft <br /> COMMENVFS 12 <br /> 4- <br /> 6c,( w ^ (7 ;: <br /> PE SC Received (Check#0 Amount Date Permit/ Invoice# Well ID# <br /> Code Info B Remitted Service Re uest <br /> a q 0 t <br /> 17 j W'9 l <br /> AMU. "P OJI-1 14 <br /> EHD 43-06 6/11/2019 WELL/PUMP PERMIT <br />