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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1866 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232(209)466-3420 <br /> NON-REFUNDABLE PERMIT www.sjgov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> Ln <br /> O'.o N� C17YIZIP RtPUN , 9S366 <br /> Joe ADDRESS I Z2L; i�1- C / IZ.rA0 <br /> / D <br /> CRO33STREET 81 01 t-A N� 1 APN cbl600 l 7 J _PARCEL SIZE r(��i LAND USE APPLICATION K A <br /> OWNER NAME Ln-__ yC- '-I Y Ir FG V ri' s PHONE v! <br /> y OW r�CJS� L / <br /> I"3`/ <br /> OWNERADDRESS �n / !il r �VC�' CITYISTATE/LP �I�nV <br /> CONTRACTOR mAi2tS[ol>E- �I,N61NCE2.I r)�, �T�flv-S J'^rAOOE.�-I.- CPMHONE�,�tct <br /> CONTRACTOR ADDRESS A0 If r��2L L,-T 021 VC'£ CITYISTATEIZJP 54ck 't/VTC) ClC7 c r LA y6 11 1 <br /> c7� CCS-YT..77 LTPCR-AZ TUN C PHONE Z� �J�//r—'?-SSUBCONTRACTORICONSULTANT 4 ) <br /> SUBCONTRACIORICONSULTANTADDRESS 0. pCT7t 1 3 CITYISTATEIZIP <br /> LICENSE a C-57 C-61 �M9 Other NUMBER 8-40'461 EXPIRATION DATE <br /> BILLING PARTY: OWNER )CONTRACTOR SUB CONTRACTOR/C ONSULTANT <br /> DOMESTIC WELL SAMPLING:.,General Mineral/Coliform Bacteria(4391) 1 Dibromochloropropane(4392)11 Arsenic(4393) <br /> INTENDED USE .Domestic/Private C Irrigation/Agricultural L Industrial Water Quality Monitoring :(Soil Sampling/Characterization <br /> Public Water System "/IZAVIS'(r,`�!'r4fK. <br /> If di6erent from Owner: Water Syetem Name Conrad Name or Pnono Numbef <br /> TYPE OF WORK I I New Well ❑Replacement Well CI Well AlteralionlModificalion 7 Other <br /> D Monitoring Well(s) #of wells X Soil Bodng(s) 3 p of borings ,1 Geotechnical x of io rirvgs <br /> O Out-Of-Service Well i I Out-Of-Service Well Renewal :7 Cross-Connection Repair <br /> i I New Pu PuW Replacement Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary Air Rotary P Auger Cable Tool C Push Point a Other <br /> Proposod Weil Depth h i it Excavation in diameter 11 Open Bottom L Gravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter I Conductor Casing Depth ft <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Schad f Steel Ll Plastic I Stainless Steel I.-I Other <br /> Grout Seal Depth /' ft h-Neat Cement(941b bag/5-10 gal water) t l Sand Cement sack mixr7 gal water <br /> Benlonile(20%solids) -t Other <br /> Grout Placement Method Pumped ;,Free Fall i Other D Retardant/Accelerator(namo) <br /> IPEOESTAL Installed By Driller i; Pump Contractor Other <br /> t Concrete Pedestal-Dimensions:Width (t Length ft Thick in L Christy Box Stove Pipe <br /> PUMP <br /> Submersible-,Turbine rJ Other HP Pump Set__ft Standing Water Level tl <br /> 1 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 /> MIINN114UU�M 48 HOUR A ANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED /%�f� �' TITLE ' "��.'t�.r s/� DATE <br /> E�MEN r <br /> C 03 ?O?O <br /> Q�[N C <br /> ouiv <br /> pq RTMFNT y <br /> DEPARTMENT USE ONLY 1 <br /> Application Accepted By Dale S 0 LO Area L L Employee ID# <br /> Grout Inspection By Date CJ SPECIAL Well Permit <br /> Pump Inspection By Dale i WAIVER Received <br /> Soil Boring Lection By DateZ`0 Constructed Well Depo ft <br /> COMMENTS [[(',,,, 'I' L 't-( 1 i'r�s:"K� ^'✓'c'r 'S rit'rCf'=/ <br /> PE Sc Received Check#I Amount Perm6u. <br /> Codes Info By Cas Remitted Date Service Re # Invoice# Well ID# <br /> LHU 47-06 61112019 Wt LL(PUMP PERMH <br />