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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 /> LA <br /> 52 5 N M -,c) )% I a n ) <br /> Jos ADDRESS �_� � Q Flocif CITYZP�CL'•M i r�� `-ISJ;�C <br /> R7 ,.-r o <br /> CROSSSTREET CY(CI {5�C'-,(,YG,MC•l�\(i <br /> AP "ICV-C.,PC PARCELSIZE T LAND USE'A]PPLIICATION 1f�] ^/ o <br /> OWNER NAME �CP-+� S L, TL%S PHONE 1 r 1 :;( , / -�N 73 4 <br /> OWNER ADDRESS Sa M� CITY/STATEZP 5C%X% <br /> CONTRACTOR V C I1`� I / :, 1��1 t 17 h PHONE <br /> CONTRACTOR ADDRESS R. So AA <br /> `I 2 CITY/STATEZ /�'P &C� 1�� ` A <br /> SUBCONTRACTOR/CONSULTANT PHONE <br /> SUBCONTRACTOR/CONSULTANT ADDRESS CITYISTATTEZP 7 <br /> LICENSE )kC-57 C C-61 I D-09 Other NUMBER ^' EXPIRATION DATE <br /> BILLING PARTY: i_OWNER >(CONTRACTOR -1 SUBCONTRACTORICONSULTANT <br /> DoMEsTic WELL SAMPLING:A General Mineral/Coliform Bacteria(4391),1!'Dibromochloropropane(4392)i_'Arsenic(4393) <br /> INTENDED USE .DomesticJPrtvele Inigation/Agncuftural Industrial Water Quality Monitoring 7 Soil Sampling/Characterization <br /> Public Water System <br /> If different from Omer: Water System Name Contad Name or Phone Number <br /> TYPE OF WORK )(New Well - Replacement Well Well Afteration/Modification Other <br /> Monitoring Well(s) #of wells Soil Boring(s) *.I bonny : Geotechnical a of bO0"gs <br /> Out-Of-Service Well _ Out-Of-Service Well Renewal Cross-Connection Repair <br /> New Pum -i Pump Replacement -Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method.114Aud Rotary C Air Rotary Auger Cable Tool Push Point _ Other <br /> Proposed Well Depth �ft Excavation in diameter Open Bottom Gravel Pack/Gravel Size )/4 in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth it <br /> Well Casing Diameter_(,�_in Thickness/Gauge/ASTM Sched(-�'a-,L -_;Steel *Plastic Li Stainless Steel 7 Other <br /> Grout Seal Depth 1 CCS It I Neat Cement(94 lb ba915-10 gal water) 3(Sand Cement '�} 5 sack mixR gal water <br /> Bentonite(20%solids) ,.i Other <br /> Grout Placement Method umped :]Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By )kDriler ❑Pump Contractor Other <br /> n <br /> ocrete Pedestal❑Dimensions:Width�_it Length it Thick in F,Christy Box F Stove Pipe El <br /> PUMP ubmersible_�Turbine G Other HPC Pump SetIy 5 it Standing Water Level 9 Cl 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 /> WORKERS COMPENSATION LAWS. <br /> MINIM /n7 8 HOUR ADVANCE NOTICE REQUIRED FOR iNSPECI'iO�VS-PLEASE SE CALL(209)953-7697 <br /> SIGNED �, TITLE t C L' Iy t S t q Ce n 4 DATE C)_ 9 L' <br /> I <br /> RECMENT <br /> EIVEp <br /> MAYO 6 2020 <br /> It 1 A JOgQUIIN COUNTY <br /> NVRONq <br /> ' STH DEPAMENTRTMENT <br /> DEPARTMENT USE ONL <br /> CrC <br /> Application Accepted By��' h� E Dale :' 41) Area / i Employee[D# <br /> Grout Inspection By Date E7 ❑ SPECIAL Well Permit <br /> c i0 1 12,2'!.J ❑ WwvER Received <br /> Pump Inspection By :r'\Ai-�bjy..-(��lL�j_ _ Date <br /> Soil Boring Inspection ByDate_ Constructed Wel Depth ft <br /> COM ENTS G:✓✓L� _Sty e Ltitl l� I(Jt -4> i(1 S- L x,5 ts4C1 <br /> PE SC Received Check#/ AmountDatePermit/ Invoice Well Codes Info Caa Remitted to Ra estM <br /> Glu <br /> O I <br /> EHU 43-06 6/112919 WELL/PUMP PERMIT <br />