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PS-6 CITY/ZIP <br />PHONE u./e,q5- CONTRACTOR /Ze /4,65 <br />CITY/STATE/ZIP SUBCONTRACTOR/CONSULTANT ADDRESS <br />OWNER I CONTRACTOR BILLING PARTY: SUBCONTRACTOR/CONSULTANT <br />JOB ADDRESS 42 4-( <br />CROSS STREET APN <br />ke4,-- 71-5:4/x4 — <br />OWNER ADDRESS 7Cgi Kde Rd <br />PARCEL SIZE /LI LAND USE APPLICATION # <br />PHONE <br />Z6-st ti4 <br />ect, <br />Doi) gpiq <br />-rhooia lid44 <br />CONTRACTOR ADDRESS PO • :4C_ CITY/STATE/ZIP 2 1/ <br />SUBCONTRACTOR/CONSULTANT PHONE Ze? 2) <br />LICENSE Cite-57 E C-61 0 D-09 0 Other NUMBER / EXPIRATION DATE Z <br />OWNER NAME <br />CITY/STATE/ZIP <br />Pump Set 474 ft Standing Water Level // ft ubmersible 0 Turbine 0 Other HP PUMP <br />Sand Cement ft 0 Neat Cement (94 lb bag/5-10 gal water) <br />Grout Placement Method 11 Pumped 0 Free Fall E Other 0 Retardant / Accelerator (name) <br />ft Thick in E Christy Box E Stove Pipe <br />PEDESTAL Installed By E Driller 0 Pump Contractor E Other <br />Concrete Pedestal 0Dimensions: Width ft Length <br />WELL CONSTRUCTION <br />Mud Rotary 0 Air Rotary 0 Auger 0 Cable Tool 0 Push Point E Other <br />Depth ft Excavation in diameter 0 Open Bottom 0 Gravel Pack/Gravel Size <br />Conductor Casing in diameter / Conductor Casing Depth <br />Diameter in Thickness/Gauge/ASTM Sched 11 Steel E Plastic E Stainless Steel <br />Depth <br />Bentonite (20% solids) 0 Other <br />ft <br />0 Other <br /> sack mix/7 gal water <br />in diameter <br />Drilling Method <br />Proposed Well <br />Well Casing <br />Grout Seal <br />'7 <br />APE , _ <br />e-tv <br />Application Accepted By <br />Grout Inspection By <br />Pump Inspection By (kr Aj. es (' `S( (94.512.. 044 <br />Soil Boring Inspection By <br />COMMENTS <br />Area <br />Date IA SPECIAL Well Pe <br />Date 3( zoLl WAIVER Received <br />Constructed Well Depth Date <br />DEPARTMENT USE ONLY <br /> Date (041 <br />ft <br />L <br />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 />DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic (4393) <br />INTENDED USE <br /> <br />0 Domestic/Private E Irrigation/Agricultural 0 Industrial E Water Quality Monitoring D Soil Sampling/Characterization <br />Public Water System <br />If different from Owner: Water System Name Contact Name or Phone Number <br />TYPE OR WORK E New Well E Replacement Well <br />Monitoring Well(s) # of wells <br />Out-Of-Service Well <br />LI New Pump tfq. Pump Replacement <br />Well Alteration/Modification U Other <br />Soil Boring(s) # of borings <br />E Geotechnical # of borings <br />Out-Of-Service Well Renewal E Cross-Connection Repair <br />Pump Repair O Raise Well Casing <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 />MINI UM 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />SIGNED <br />TITLE 15-2,1--14-4-1-21 DATE Z L45 - <br />PE <br />Codes <br />SC <br />Info <br />Received <br />B <br />Check#/ <br />Cash <br />Amount <br />Remitted Date <br />' ! <br />Permit/ <br />,5ervice Request # Invoice # Well ID# <br />1.13F I os-o WU <br />I( <br />V( 111 4'77 lArtin0q1 Tf?- )M2-I :SS3HCICIV allS el#4* 1 2 11r1V2i5 EHD 43-06 6/11/2019 WELL /PUMP PERMIT