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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 /> �QQI S• F_1 DorQde 5� �t�h� �a�wt� 9sa31 m <br /> JOB ADDRESS CITY/ZIP m <br /> Q <br /> CROSS STREET�I- V POY-1 \ APN <br /> OWNER NAME ��`�,� 3' PARCEL SIZE �I f 3 LAND USE APPLICATION# 0 <br /> PHONE 269 - (OL Z-,2,,// In <br /> l7i <br /> ��� \' /+ ✓ /� L� 2 <br /> OWNER ADDRESS 6�0 CITY/STATE/ZIP �/lchl(l CA { 5'Z51) <br /> CONTRACTOR k6Oy-mad S Ww'►tA' Sy slemS Inc, P'' N� <br /> H''O//NE <br /> CONTRACTOR ADDRESS Z�ZO Wilcox '.d CITY/STATE/ZIPSbC�Dn' CA q5;7_1✓` <br /> SUBCONTRACTOR/CONSULTANT PHONE <br /> tA <br /> SUBCONTRACTOR/CONSULTANT ADDRESS CITY/STATE/ZIP <br /> LICENSE )(C-57 ❑ C-61 Ll D-09 ❑ Other NUMBER 11(Pp R1& EXPIRATION DATE 1 2 <br /> BILLING PARTY: 7 OWNER %CONTRACTOR J SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING: ❑ General Mineral/Coliform Bacteria (4391) ❑ Dibromochloropropane (4392) ❑ Arsenic(4393) <br /> INTENDED USE K Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil 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 ❑ Other <br /> ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings ❑ Geotechnical I W11c <br /> ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair Ep CD <br /> ❑ New Pum Pump Replacement ❑ Pump Repair ❑ Raise Well CasingSC <br /> WELL CONSTRUCTION <br /> Drilling Method ❑ Mud Rotary 11 Air Rotary 11 Auger 11 Cable Tool ❑ Push Point El Other k FNVRgWNC <br /> Proposed Well Depth ft Excavation in diameter Ll Open Bottom F1 Gravel Pack/Gravel Size �FpA ar3leter <br /> ❑ Conductor Casing in diameter / Conductor Casing Depth ft fFNT <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑ Steel ❑ Plastic ❑ Stainless Steel ❑ Other <br /> Grout Seal Depth ft ❑ Neat Cement(94 Ib bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water <br /> ❑ Bentonite(20%solids) ❑ Other <br /> Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other <br /> ❑ Concrete Pedestal❑Dimensions:Width ft Length ft Thick in J Christy Box ❑ Stove Pipe <br /> PUMP Submersible[] Turbine ❑ Other HP_« Pump Set ft Standing Water Level <br /> I HEREBY C 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 /> MINIMUM 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS -PLEASE CALL (209) 953-7697 <br /> SIGNED TITLE DATE <br /> DEPARTMENT USE/ ONLY <br /> Application Accepted By �Z__ Date /ay/ O`er Area I e?C� Employee ID# <br /> Grout Inspection By ( Date ElSPECIAL Well Permit <br /> Pump Inspection By -b-0 U"W-t t- Awi, Date U "II(ILO i ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check# Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B Remitted S rvice Request# <br /> NN3F os0 b ¢77 - •ZD <br /> EHD 43-06 6/11/2019 WELL/PUMP PERMIT <br />