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t <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 OV.00 /ehd XPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS , CITY/ZIP I T ti m <br /> I�,�r�l-�� cl . <br /> CROSS STR APN 1 /� PARCEL SIZE LAND USE <br /> /APPLICATION <br /> # o <br /> OWNER NAME �JY _ ()Q /�/( PHONE IL/ UI/l/� �� m <br /> j� m <br /> OWNER ADDRESSBox459)pCITY/STATE/ZIP (/I l/ ��JI ��tq <br /> CONTRACTOR. '//� PHONE(/()&7I(q5/'�(/t/ <br /> CONTRACTOR,ADDRESS !/ CITY/STATE/ZIP �J�J�' n'751- <br /> SUBCONTRACTOR/CONSULTANT <br /> �J <br /> SUBCONTRACTOR/CONSULTANT n(PH//O��NE.OW— 'ol � {'/� <br /> SUBCONTRACTOR/CONSULTANT ADDRESS —aq ITY/STATE/ZIP ff[/{C-JI( J l y 1 <br /> LICENSE �C-57C-61 ❑ D-09 ❑ Other NUMBER EXPIRATION DATE <br /> BILLING PARTY: ❑OWNER ❑CONTRACTOR LI SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391)A Dibromochloropropane(4392) ❑ Arsenic(4393) <br /> INTENDED USE 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 Jew 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 <br /> ❑ New Pump ❑ Pump Replacement ❑ 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 '�Fc� ft Excavation I1 in diameter ❑ Open Bottom rGravel Pack/Gravel Size Y/,& in diameter <br /> ❑ Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter Es in Thickness/Gauge/ASTM Sched 900 ❑ Steel 91�plastic C Stainless Steel ❑ Other <br /> Grout Seal DepthyO i- ft ❑ Neat Cement(94 Ib bag/5-10 gal water) Pt Sand Cement sack mix/7 gal water <br /> ❑ Bentonite(20%solids) ❑ Other <br /> Grout Placement MethodY Pumped ❑ Free Fall ❑ Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ DrillerL-'Pump Contractor ❑ Other <br /> ❑ Concrete Pedestal❑Dimensions:Width 0- ft Length 2 ft Thick_�in ❑ Christy Box ❑ Stove Pipe <br /> PUMP Submersible❑ Turbine ❑ Other 111.51- 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 /> MINIM 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS -PLEASE CALL (209) 953-7697 <br /> SIGNED ' TITLE IIUJ4� DATE I _2 a <br /> R <br /> DEPARTMENT USE ONLY <br /> Application Accepted By < <–L— Date /t d d0I U Area // 7 Employee ID#� <br /> Grcu:Inspection By Date Gvn ❑ SPECIAL Well Permit <br /> Pump Inspection By �'Grn,i Date 7 2 Zl WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS +IVP( 'S5V ed cot- loll } Sr=.,1 depth JFf - Uj - W10 t" <br /> W, rbc AI -444 „jc,he'y t..lelt <br /> PE SC Received Ch Amount ate Permit/ Invoice# Well ID# <br /> Codes Info B Remitted Service Request# <br /> WO 0 414--73 <br /> WPO 4—(47 <br /> `139' soW F.00 414 73 <br /> 70 P 4 l 3 <br /> EHD 43-06 6/11/2019 WELL/PUMP PERMIT <br />