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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 <br /> /1 YEAR FROM DATE ISSUED <br /> Lil <br /> JOB ADDRESS ZITrA) CITY/ZIP m <br /> CROSS STREET _ APN �J PARCEL SIZE ,3 I LAND USE APPLICATION# o <br /> _ m <br /> OWNER NAME t�DS i�f LEV-,I2�� PHONE ,;Rd�7 -71— 7 v <br /> OWNER ADDRESS �fj � CITY/STATE/ZIP �G}� <br /> CONTRACTOR [yL�ji/�/� � � ,/� ��yJs PHONE /' <br /> CONTRACTOR ADDRESS �� !�1/J`/�'G /� CITY/STATE/ZIP / <br /> SUBCONTRACTOR/CONSULTANT z G L-f J PHONE -1 <br /> SUBCONTRACTOR/CONSULTANT ADDRESS CITY/STATE/ZIP <br /> LICENSE V/ -57 � Ely <br /> -61 D-09 ❑ Other NUMBER l6OpIZ, EXPIRATION DATE <br /> BILLING PARTY: ❑OWNER ❑CONTRACTOR ❑ SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING:5,General Mineral/Coliform Bacteria (4391);'Dibromochloropropane (4392) ❑ Arsenic(4393) <br /> INTENDED USE Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Char�rty�rffip o C <br /> ❑ Public Water System ENT <br /> If different from Owner: Water System Name Contact Name or Phone Nu <br /> TYPE OF WORK ❑ New Well dePeplacement Well ❑ Well Alteration/Modification ❑ Other <br /> ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings ❑ Geotechnical AUG# f f rirf� 20 <br /> ❑ Out-Of-Service Well 0 Out-Of-Service Well Renewal ❑ Cross-Connection Repair SAN JOAQUIN COUNTY <br /> UO�Jew Pump ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casing ENV <br /> WELL CONSTRUCTION LTH DEPARTMENT <br /> Drilling Method Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point 0 Other <br /> Proposed Well Depth ZJ56 ft Excavation /Z- in diameter ❑ Open Bottom ravel Pack/Gravel Size in diameter <br /> ❑ Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter. �, Thic_kness/Gauge/ASTM Sched G' Z ❑ Steel Mastic ❑ Stainless Steel ❑ Other <br /> Grout Seal Depth_ /5,2'r e'fCL�s❑ Neat Cement(94 Ib bag/5-10 gal wafer) ❑ Sand Cement sack mix/7 gal water <br /> Bentonite(20%solids) ❑ Other <br /> Grout Placement Method JVPumped ❑ Free Fall 0 Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By 0 Driller Lump Contractor ❑ Other <br /> ❑ Concrete Pedestal ❑Dimensions:Width___Zit Length ft Thick�_in ❑ Christy Box ❑ Stove Pipe <br /> Pump Submersible❑ Turbine ❑ Other HP Pump Set /YD It Standing Water Level -ft- <br /> I HEREBY CE TIFY 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 /> M� H VANCE NOTICE REQUIRED FOR INSPECTIONS -PLEASE CALL(209) 9V-7p97 <br /> SIG ED / TITLE �r"' DATE <br /> r 7 <br /> P" <br /> C <br /> ,n C <br /> r- <br /> -r C <br /> cn <br /> 's <br /> JJ DEPARTMENT USE ONLY <br /> Application Accepted By � L/ 1/ Date 0/1dodo Area Employee ID# DA <br /> Grout Inspection By Date 7.02(7 ' SPECIAL Well Permit <br /> Pump Inspection By ��wnc�4(;; �i'�/w/r, �1 Date (Z(;j �: c� ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS 1,'I'C,b MP ��,}�.,n {j p� r�6' . 5/Zc �o t. 0 ce iSg <br /> t a q <br /> PE SC ReceivedChec Amount Date Permit/ Invoice# Well ID# <br /> Codes Info Cash Remitted I Service Request# <br /> *Luo <br /> 43-1( <br /> LI39d I W -'7v <br /> EHD 43-06 6/11QO19 WELL/PUMP PERMIT <br />