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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.S Ov.or lehd EXPIRES 1 YEAR FROM DATE ISSUED Sn <br /> JOB ADDRESS CIN/ZIP m <br /> CROSS STREET APN PARCEL SIZE°LAND USES APPLICATION# A <br /> PHONfV Y7 <br /> / r �! <br /> OWNER NAME / <br /> � <br /> OWNER ADDRESS CITY/STATE/ZIP ' ���"/�]6� 4? /LJ <br /> CONTRACTOR P{H�OJE 2— /—q��'Q�OVILe/ <br /> &A 2!�� <br /> CONTRACTOR ADDRESS CITYISTATE/ZIP C/►[/� /Sd�S <br /> SUBCONTRACTOR/CONSULTANT on PHON <br /> SUBCONTRACTOR/CONSULTANT ADDRESS CI /STATE/ZIP <br /> LICENSE VC-57 0 C-61 ❑D-09 ❑Other NUMBER EXPIRATION DATE <br /> BILLING PARTY: G OWNER CONTRACTOR J SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING:❑General Mineral/Coliform Bacteria(4391)'_1 Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE Domestic/Private ❑ Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring :1Soil Sampling/Characterization <br /> ❑ Public Water System <br /> If different from Owner. Water System Name Contact Name or Phone Number <br /> TYPE OF WORK ❑ New Well ❑Replacement Well ❑Well Alteration/Modification 0 Other <br /> ❑Monitoring Wells) #of wells G Soil Borings) #of borings 0 Geotechnical #of borings <br /> 0 Out-Of-Service II ❑Out-Of-Service Well Renewal 0 Cross-Connection Repair <br /> 0 New Pump OKPump Replacement 0 Pump Repair 0 Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method ❑Mud Rotary 0 Air Rotary ❑Auger ❑Cable Tool 0 Push Point ❑ Other <br /> Proposed Well Depth ft Excavation in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter <br /> ❑Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Sched ❑Steel 0 Plastic ❑Stainless Steel 0 Other <br /> Grout Seal Depth ft ❑Neat Cement(941b bag/5-10 gal water) ❑Sand Cement sack mix/7 gal water <br /> 0 Bentonite(20%solids) 0 Other <br /> Grout Placement Method ❑Pumped ❑ Free Fall ❑Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑Driller 0 Pump Contractor ❑ Other <br /> ❑Concrete Pedestal❑Dimensions Width ft Length It Thick in ❑ Christy Box 0 Stove Pipe <br /> PUMP Submersible❑Turbine ❑Other HP Pump Set C —ft Standing Water Level <br /> I HEREBRTI <br /> Y CEFY 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 COMP ISATION WS. <br /> MINI A OTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209),95 �T6 fi <br /> SIGNED TITLE�zlk- l DATE ! Z <br /> AENT <br /> El <br /> fVED <br /> 2020 <br /> TIEDA <br /> N COUNTY <br /> 77— <br /> H ENTAL <br /> DEPARTMENT USE ONLY �� ARTAlIENT <br /> Application Accepted By L � Date t I r� �U Area y Employee ID#� <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection By k r N^L%)L1 Date � ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE Sc Received Chec Amount Date Permitt Invoice# Well ID# <br /> Codes Info B ash Remitted Service Re uest# <br /> W3si no 11 <br /> EHD 43-W 6/112019 WELL/PUMP PERMIT <br />