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b. <br /> WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232(209)468-3420 <br /> NON-REFUNDAB P RMI WWW.S OV. /ehd EXPIRES,1,YEAR FROM DATE ISSUED <br /> JOB ADDRESS t( • u2 CITY/LP <br /> CROSS STREETj(PYI,I c *'I F' APN 0OS 0 -+ PARCEL SIZE LAND USE APPLICATION# ' <br /> OWNER NAME pzvict �jI PHON 40 <br /> CONTRACTOR <br /> OWNER ADDRESS / L CITYISTATE/ZIP 0 <br /> CONTRACTOR C PHONE e ,� 1^/� <br /> CONTRACTOR ADDRESS I /� "'�L` J 1"2CITY/STATFJZIPl.LC.�'I �V/C. <br /> SUBCONTRACTOR/CONSULTANT L L L `" PHONE <br /> SUBCONTRACTORICONSULTANT ADDRESS CI�rp( <br /> T�Y��ILS�TtA`TE/ZIP <br /> LICENSE C-57 C C-61 C D-09 J V—1 Other NUMBER 'l PIRATON DATE <br /> BILLING PA OWNER CONTRACTOR - SUBCONTRACTORICONSULTANT <br /> DOMESTIC WELL SA PLING:X General Mineral/Coliform Bacteria(4391);<Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE ^omesticlPrivate C Irrigation/Agricultural 0 Industrial G Water Quality Monitoring c Soil Sampling/Characterization <br /> 0 Public Water System <br /> If different from Owner Water System Name Contact Name or Phone Number <br /> TYPE OF WORK . New Well AReplacement Well L Well Alteration/Modification L Other <br /> J Monitoring Wells) #of wells C Soil Bodng(s) a of b0finoe _J Geotechnical a or bormp <br /> Out-Of-Service Well C Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> J New Pump C Pump Replacement D Pump Repair J Raise Well Casing <br /> WELL C N TR C N <br /> Drilling Metho ud Rotary Air Rotary E Auger J Cable Tool i Push Point L7 Other <br /> Proposed Well Depth Excavation (t")—in diameter '7 Open Bottom ravel Pack/Gravel Size in diameter <br /> LC onduc r Casing in diameter / CO <br /> ct Casing Depth It <br /> Well Casing Diame er In Thickness/Gauge/ASTM Sche Steel Mastic r Stainless Steel C Other <br /> Grout Seal `D,epth ft rl Neal Cement(94 lb bag/5-10 gal water) ❑Sand Cement sack man gal water <br /> �lBentonite(20%solids) i!Other <br /> Grout Placeme t Method Vpumped ❑Free Fall C Other J Retardant/Accelerator(name) <br /> PEDESTAL Installed By C Driller 4IQ5ump Contractor C: Other <br /> -3 Concrete Pedestal OD ensions:Width it Length It Thick in ❑Christy Box 0 Stove Pipe <br /> PUMP 0 Submersible❑Turbine CI Other HP Pump Sel it 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. 1 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 Aft H A VANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209 95, 97 <br /> SIGNED TITLE I)r 1, DATE <br /> E�MFNT <br /> 5 2C <br /> 9 2020 <br /> i TMFNT <br /> DEPARTMENT USS ONLY <br /> Application Accepted By �_ Date jo Area rr�f Employee ID# DA <br /> _ <br /> Grout Inspection By Dale SPECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Inspectior�6y Date Constructed Well Depth ft <br /> COMMENTS o 00Al . ,� I b.tlM r T11 6 v - C d .S. <br /> PE Sc Received Check#/ Amount Date PermlV Invoice# Well ID# <br /> Codes Info Cash Remitted Servic Re uest# <br /> 370 O O <br /> 4?rid 4 70 <br /> EHD 43-06 6111/2019 WELL/PUMP PERMIT <br />