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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTIi DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232 (209)468-3420 <br /> I\10N-REFUNDABLE_PERMIT 1n <br /> �,,e AL EXPIRES I YEAR FROM DATE ISSUED <br /> JOB ADDRESS &71K�"� �`" CITYIZIP � 'o, •d-36 m <br /> - —' <br /> r D <br /> CROSSSTREET_DO APN ao7aaoas PARCEL SIZE /70 <br /> 1LAND USE APPLICATION# A <br /> y PHONE�Lb�—k3 13 re N <br /> OWNER NAME q <br /> OWNER ADDRESS _ I�Q 4 I � CITY/STATE/ZIPco <br /> CONTRACTOR - n ! /�G PHONE L <br /> CONTRACTOR ADDRESS CITYIS TATE/ZIP <br /> SUBCONTRACTORICONSULTAN'T PHONE <br /> SUBCONTRACTORICONSULTANT ADDRESS CITY/STATE/ZIP <br /> LICENSE D C-57 D C-6.1 __LLL)-0q 0 OtherNUMBER EXPIRATION DATE <br /> BILLING PARTY: OWNER i CONTRACTOR SUBCONTRACTOR/CONSULTANT <br /> x <br /> DOMESTIC Wr-LL SAMP ING:I General Mineral/Coliform Bacteria(4391)11 Dibromochloropropane(4392)I;Arsenic(4393) <br /> INTENDED Usr_ . omestic/Private ❑ Irrigation/Agricultural 0 Industrial ❑ Water Quality Monitoring 0 Soil Sampling/Characterization <br /> 0 Public Water System--__If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK n New Well D Replacement Well 0 Well Alteration/Modificalion D Other <br /> IJ Monitoring Well(s) #of wells ❑ Soil Boring(s) 'of borings ❑ Geotechnical It of borings <br /> Out-Of--Service Well D Out-Of-Service Well Renewal LI Cross-Connection Repair <br /> ❑ New Pump ❑ Pump Replacement D Pune Repair 1i Raise Well Casio <br /> WELL CONSTRUCTION <br /> Drilling Method ❑ Mud Rotary O Air Rotary ❑ Auger ❑ Cable Tool D Push PUII'It 0 Other <br /> Proposed Well Depth ft Excavation — In diameter D Open Bottom f7 Gravel Pack/Gravel Size in diameter <br /> D Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Lasing Diameter— in Thickness/Gauge/ASTM Sched D Steel 0 Plastic ❑ Stainless Steel D Other <br /> Grout Seal Depth_ ft D Neat Cement(94 Ib bag/5-10 gal wafer) D Sand Cement sack mix/7 gal water <br /> n Bentonite(20%solids) 0 Other <br /> Grout Placement Method fa Pumped ❑ Free Fa D Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed B-7 D Driller VPump Contractor D Other <br /> ❑ Concrete Pedestal 0Dimensions:Width ft Length ft Thick in 0 Christy Box 0 Stove Pipe <br /> rpump D SubmersibleD Turbine D Other HP Pump Set ft Standing Water Level ft <br /> I HEREBY CERTIFY THAI' I HAVE PREPARED THIS APPLICATION AND THAM 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 /> MIN U 48 HO R ADVANCE NOTICE REQUIRED FOR INSPECIFIONS -PLEASE CALL.(209) P53697 <br /> SIGNED_ --_-- __- TITLE 411%_- �- DATE <br /> L EAT] <br /> — — — — <br /> An <br /> -- — — -- 4011 j <br /> 8 - <br /> SA A U C U <br /> HE -- — ---- — — — <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date Area Employee ID# S�C <br /> Grout Inspection By Date a SPECIAL Well Permit <br /> Pump Inspection By krutvLl., br"a"C, Z Date ] ❑ WAIVER Received <br /> Soil Boring Ins ection By - -� Date Constructed Well Depth ft <br /> . <br /> COMMENTS A4e.,- /"1°Yvlc+iln 0115 6;j7- -bF S e,vhe— &r 'rivee s Well 1way be teilled <br /> be orb-pef Iv abancAGv r deshwea. <br /> PE SC Received Check Amount Date Permit! Invoice# Well ID# <br /> Codes Info B as Remitted Service Re uest# <br /> 436' i7t #laa <br /> EHD 43-06 6111/2019 WELL/PUMP PERMIT <br />