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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1666 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232(209)4663420 <br /> NON-REFUNDABLE PERMIT www.sjgov,.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> "n".1 /� I l Sz L7o m <br /> JOB ADDRESS / •--( KO C.K\ f. pie_ CrTYILL 0 DP I A <br /> CROSS STREET KPI/n O t d S I�Lorr�j �G APNe� O PARCEL SIZE? i Qr rQLAND USE APPLICATION#1C C o <br /> OWNER NAME ' \ PHONE 207 <br /> OWNER ADDRESS 1 -I i tN• ,1 C:[^ WV 2 / <br /> CONTRACTOR �'�� i[, AI deI`QOrlf II/Iy�SOCiatQ,: PHONEn 20�-36� - 51/10 ( <br /> CONTRACTOR ADDRESS O Z I n CA,(S{r n(, W o,I{ CfTY/STATElZW L CCS- <br /> SUSCONTRACTOR/CONSULTANT 30'—e"' PHONE <br /> SUBCONTRACTOR/CONSULTANT ADDRESS ���+YID- CITYISTATE2I(P. �n'`"e- <br /> LICENSE <br /> LICENSE 1k C-57 C-61 -D-09 Other NUMBER b y C) 0 [I EXPIRATION DATE O} / I / 02 i <br /> BILLING PARTY: ` OWNER XCONTRACTOR ISUBCONTRACTORICONSULTANT <br /> DOMESTIC WELL SAMPLING:i i General Mineral/Coliform Bacteria(4391)Fl Dibromochloropropane(4392)i Arsenic(4393) <br /> INTENDED USE Domestic/Private i Irrigation/Agricultural Industrial L 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 U Well Alteration/Modification Other <br /> Monitoring Well(s) #of wells n Soil Bonng(s) #of borings (Geotechnical_, ._p°(borings <br /> Out-Of-Service Well U Out-Of-Service Well Renewal a Cross-Connection Repair <br /> New Pump Pump Replacement a Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary Air Rotary )(Auger L Cable Tool Push Point Other <br /> Proposed Well Depth 3 o It Excavation in diameter I Open Bottom Gravel Pack/Gravel Size in diameter <br /> i Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter�L In Thickness/Gauge/ASTM Schad Steel : Plastic Stainless Steel Other <br /> Grout Seal Depth ft X Neat Cement(94 to bag/5.10 gat water) Sand Cement sack mix/7 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method Pumped Free Fall i Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By :Driller Pump Contractor Other A <br /> Concrete Pedestal !Dimensions:Width ft Length It Thick in i j Christy Box i Stove Pipe <br /> PUMP i Submersible r'Turbine i Other HP Pump Set ft Standing Water Level ft /11 <br /> 1HEREBY 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. 1 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 p <br /> COMPENSATION LAWS. <br /> woRKE MINIMUM 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 S A,✓Q�^/ o��O <br /> SIGNED "1 lLL lam. I �.t.Ct v TITLE �a l'I CI�IQ t n2.Q�{� DATE �d I l 'Y �R W2,0 <br /> Ty Fp RST CO <br /> MFNT <br /> IT <br /> 41 1 1 _71 I <br /> 0 <br /> 1 EPARTMENT/ USE NLY <br /> Application Accepted By Date (� I Area ` LG t Employee ID# I G r( <br /> Grout Inspection By Date UX!ZU' <br /> I-L) I SPECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS p,- 1 tea r Aqjr (rare <br /> PE SC Received Check#/ Amount PermW <br /> Codes Info Cas Remitted Date Service Request# Invoice# Well ID# <br /> p Io 0 <br /> EHD 43-06 6/1112019 //� i1 /��� WELL/PUMP PERMfT <br />