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• )$;3 <br /> WELL!PUMP PERMIT <br /> SAN JOACt/►NCOUNTY ENVIRONfvIENTALHEALTH DEPARTMENT <br /> 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 X252 (209)468-3420 <br /> NON-REFUNDABLE PERMIT <br /> WWW.S OV.Of /ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 25823 E.Carter Rd. <br /> CITY/ZIP Escalon 95320 <br /> M <br /> CROSS STREET F�IorFBelbtand. AIS 187-25-007 11032 D <br /> ` PARCEL SIZE LAND USE APPLtCAT10N# Ra <br /> OWNER NAME Vftner Oalq Ricca rcj "- <br /> PHONE -992-0326 <br /> OWNER ADDRESS 22176Skiff Rd �! <br /> CITYISTATE/7JP Escak)n95320 <br /> CONTRACTOR <br /> IC( <br /> CONTRACTOR ADDRESS V !P ! W CITY/STATE/Z8+ ,,' <br /> i <br /> k PHONE(aQ c 1 7 <br /> Id <br /> SUBCONTRACTOR/CONSULTANT 7 <br /> PHONE <br /> SUBCONTRACTOR/CONSULTANT ADDRESS <br /> CITY/STATE/ZIP <br /> LICENSE C-57 X C-61 F D-OS Other <br /> NUMBER 1055434 EXPIRATION DATE 7/31/2021 <br /> BILLING PARTY: 1 OWNER _CONTRACTOR F SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING:I General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> LLINTENDEDUSE I Domestic/Private X Irrigation/Agricultural Industrial _ Water Quality Monitoring L Soil Sampling/Characterization <br /> Public Water System <br /> tt dlrereM from Owner Water System Name <br /> Contact Name or Phone Number <br /> TYPE OF WORK I New Well I Replacement Well I Well Afteration/Modification I Other <br /> L Monitoring Weh(s) #of vvells L Soil Boring(s) a bo'ino, <br /> J Geotechnical "Y <br /> L Out-Of-Service Well I Out-Of-Service Well Renewal c'•/ /�/T <br /> L New Pum _ Pum Replacement 9 Pum Re Cross-Connection Repair,,���` �'• / <br /> WELL CONSTRUCTION _ Raise Well <br /> Drilling Method I Mud Rotary -1 Air Rotary Auger F Cable Tool - Push Point F Other OCT 2 <br /> Proposed Well Depth ft Excavation in diameter 1 Open Bottom r Gravel Pack;Gravel S JO in diameter <br /> I Conductor Casing in diameter / Conductor Casing Depth ft HF Rp Co <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched i Steel _ Plastic _ Stainless Steel AC the[)'Ep4�'4L��T—y <br /> Grout Seal Depth fl I Neat Cement(941b ba915-10 gal water) Sand Cement Sack mrx,7 g.5/X,ater <br /> Bentonite(20%solids) L Other <br /> Grout Placement Method Pumped _I Free Fall I Other I Retardant:Accelerator(name) <br /> fPEDESTAL Installed By 1 Driller F Pump Contractor 1 Other <br /> L Concrete Pedestal jDimensions:Width ft Length ft Thick in _ Christy Box -i Stove Pipe <br /> PUMP F Submersible R Turbine r Other HP 125 Pump Set ft Standing Water Level lt <br /> I HEREBY CERTIFY THAT 1 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 /> MIr I . 8 N UR ADVANCE NOTICE REQUIRED FOR INSPECTIONS -PLEASE CALL(209)963-7697 <br /> SIGNED L— Trns CEO DATE 1OW2020 <br /> IP�L <br /> i <br /> 25823 Carter <br /> -• <br /> DEPARTMENT USE ONLY <br /> Application Accepted By � Date d <br /> / am Area Employee ID#_ <br /> Grout Inspection By 1 Date SPECIAL Well Permit <br /> Pump Inspection By ,c, fes. M-c,%� Date 1012'-/47-L WAIVER Received <br /> Soil Boring Inspection By Date —_ Constructed Well Depth _ft <br /> COMMENTS <br /> PE Sc Received Check Amount Permit! <br /> Codes Into B Remitted Date Service Request# Invoice# Well ID# <br /> WEAL!PUMP PERMIT <br /> EHD 431% 6!1111019 <br />