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�vz4 c <br /> WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-62.32 (209)468-3420 <br /> NON-REFUND PERMIT Www.S ®v.Or /ehd �IEXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS C� 1 CITY/ZIP 1 tel _ <br /> m <br /> ( YIt D <br /> CROSS STREET 1 APN �3�l���OoS PARCEL SIZE 11% LAND USE APPLICATION# o <br /> OWNER NAME Cf Ic <br /> � 1- PJ'HGNfi/ J ✓ v� N <br /> OWNER ADDRES-D S ! CITY/STATE IP <br /> CONTRACTOR -1-7Gni tv/Jr) V( MD� f+ U PHONE <br /> `� <br /> CONTRACTOR ADDRES� 1 -rL �6 `J/tel q5 yjq <br /> CITY/ ATE ...JJJ <br /> SUBCONTRACTOR/CONSULTANT PHONE All <br /> SUBCONTRACTOR/CONSULTANT ADDRESS CITY/ST�AnTE/2nIP �'J1 <br /> LICENSE _ C-57 C-61 _ D-09 Other NUMBE lv W D EXPIRATION DATE U Q w <br /> BILLING PARTY: OWNER C CONTRACTOR - SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL S MPLING: D General Mineral/Coliform Bacteria (4391) = Dibromochloropropane(4392)D Arsenic.(4393) <br /> INTENDED USE Domestic/Private _: Irrigation/Agricultural - Industrial _. Water Quality Monitoring _ Soil Sampling/Charactenzation <br /> Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK New Well I_� Replacement Well U Well Alteration/Modification Other <br /> Monitoring Wells) #of wells -, Soil Boring(s) #of borings - Geotechnical #of borings <br /> _ Out-Of-Servic Well Out-Of-Service Well Renewal Cross-Connection Repair <br /> ____ = New Pump ump Replacement i Pump Repair = Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method _ Mud Rotary Air Rotary -� Auger Cable Tool Push Point _ Other <br /> Proposed Well Depth ft Excavation in diameter Open Bottom L 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 a Plastic _ Stainless Steel U Other W <br /> Grout Seal Depth ft G Neat Cement(94/b bay/5-10 gal water) " Sand Cement sack mix/7 gal water <br /> J - Bentonite(20%solids) D Other <br /> i Grout Placement Method - Pumped P Free Fall F, Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By -- Driller ❑ Pump Contractor - Other <br /> _ Concrete Pedestal uDimensions:Width ft ft Thick in _ Christy Box U Stove Pipe <br /> PI UM? Submersible- Turbine n OtherHP Pump Set W IIJ ft Standing Water Level 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 CO RTR-L)l%WS. <br /> NINIMIIM S !JOUR AD �fiGE-REQUIRED F0,B iNSPECTIONS -PLEASE CALL (209) 953-7697 <br /> SIGNED --_ `'� LTLE V l�l.l'✓I�C Y ► DATE <br /> 77 <br /> -- -- -� - - <br /> L_ /1 i <br /> I <br /> I E q U <br /> Al <br /> i A T E <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date Area S Employee ID# FR <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection By ( SC� tllw�n 1s11�1� Date � 1�I,S)Q� 11 WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE Sc Received Amount Date Permit/ Invoice# Well ID# <br /> Codes Info as Remitted Service Request# <br /> `13$1 05o 3= X7'7 <br /> EHD 43-06 6/11/2019 WELL/PUMP PERMIT <br />