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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.sjgov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS CITY/ZIP <br /> m <br /> nn__ p(�L (� n <br /> CROSS STREET��.4!!:l APN/O DO`11"' PARCEL SIZE '" LAND USE <br /> SAPPLICATION# A <br /> OWNER NAME ( 1 �1 PHON�7 C — <br /> OWNER ADDRESS CITY/STATE/ZIP <br /> .3kfajQ (_A <br /> CONTRACTOR QPPHONE?E39 /` L�(� <br /> CONTRACTOR ADDRESS Dej4d <br /> //� CITY/STATE/ZIP U[IC�C��J,(L�( �� \ <br /> SUBCONTRACTOR/CONSULTANT & yam' PHONE <br /> SUBCONTRACTOR/CONSULTANT ADDF�ESS C TY/STATE/ZIP / <br /> LICENSE C-57 ❑ C-61 ❑ D-09 ❑ Other NUMBER EXPIRATION DATE <br /> BILLING PA TY: ❑OWNER ❑CONTRACTOR ❑ SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING:❑General Mineral/Coliform Bacteria (4391)❑ Dibromochloropropane(4392) ❑Arsenic(4393) <br /> INTENDED USE Domestic/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 ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other <br /> ❑ Monitoring Wells) #of wells ❑ Soil Boring(s) #of borings ❑ Geotechnical #of borings <br /> ❑ Out-Of-Service Vell ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> ❑ New Pump Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method ❑ Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other <br /> Proposed Well Depth 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_ in Thickness/Gauge/ASTM Sched ❑ Steel ❑ Plastic ❑ Stainless Steel ❑ Other <br /> Grout Seal Depth ft ❑ Neat Cement(94 lb bag/5-90 gal water) ❑ Sand Cement sack mix17 gal water <br /> ❑ Bentonite(20%solids) ❑ Other <br /> Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other <br /> ❑ Concrete Pedestal❑Dimensions:Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe <br /> PUMP 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 /> WORK COMPENSATI WS. <br /> 1 IMU 4> 0 ,t+10E OTICE REQUIRED FO INSPE TIONS-PLEASE CALL(209) 5 -7697 <br /> SIGNE TITLE DATE <br /> MIA I <br /> G <br /> ENVI n1 _COUA Tv <br /> PA <br /> T p AL <br /> DEPARTMENT US ONLY <br /> Application Accepted By Date_96 y .0dlo Area `� Employee ID# 1 4 <br /> Grout Inspection By l� Date ❑ SPECIAL Well Permit <br /> Pump Inspection By fKtrN_""' Date �� `101,'' ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received (Check# <br /> jl Amount Date Permit! Invoice# Well ID# <br /> Codes Info B Remitted Service Reuest# <br /> y3g 0 S 77 <br /> EHD 43-06 6/11/2019 WELL/PUMP PERMIT <br />