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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 D TE ISSUED <br /> JOB ADDRESS CITY/ZIP C/7 ✓ m <br /> 2 / D <br /> CROSS STREET APN Z6 0 PARCEL SIZE SJ. ILAND USE APPLICATION# <br /> m <br /> OWNER NAME PHONE //Y/'/� �/J�, -�y^/ <br /> LrIV <br /> OWNER ADDRESSmgp (v CITY/STATE/ZIP /�(,63 <br /> amnvm <br /> J2yP <br /> CONTRACTOR PPHHrO/NE'�,71(7�y/' <br /> CONTRACTOR AD DRESS CITY/STATE/ZIP <br /> SUBCONTRACTOR/CONSULTANT PHONE <br /> SUBCONTRACTOR/CONSULTANT ADDRESS CIT /STATE/ZIP <br /> LICENSE C-57 El C-61 Li D-09 [I Other NUMBER EXPIRATION DATE <br /> BILLING PA TY: OWNER CONTRACTOR SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE F, Domestic/Private F1Irrigation/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 #of borings <br /> ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair It <br /> - New Pump Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary !I Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other <br /> Proposed Well Depth ft Excavation in diameter ❑ Open Bottom 7 Gravel Pack/Gravel Size in diameter <br /> C Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑ Steel i7 Plastic ❑ Stainless Steel I 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 Ll Free Fall ❑ Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By i i Driller ❑ Pump Contractor i Other <br /> ❑ Concrete Pedestal[]Dimensions:Width ft Length ft Thick in Christy Box ❑ Stove Pipe <br /> PUMP ubmersiblel- Turbine ❑ Other HP Pump Set 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 COMPENSATION LAWS. <br /> MINOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209) 953-7669 <br /> SIGNED TITLEy/G% DATE <br /> c <br /> Ci <br /> AVii <br /> ED <br /> R <br /> DEPAR MENT USE ONLY D <br /> mpEPART NT <br /> J t <br /> Application Accepted By Date ( C� C LjJArea 1 Eloyee ID#�( <br /> i <br /> Grout Inspection By ! Date SPECIAL Well Permit <br /> L) <br /> Pump Inspection By t VL;S�� �2r.( �_ �,ui:1� Date j ��G" WAIVER Received <br /> Soil Boring Inspection By Date onstructed Wel Depth ft <br /> "COMMENTS D Y r <br /> PE Sc Received Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B Cash Remitted Service Request# <br /> a- 41 <br /> EHD 43-06 6/11/2019 WELL/PUMP PERMIT <br />