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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-REFUNDAB PERMIT 06 WWW S gov.org/ehd EXPIRES 'I YEAR FROM DATE ISSUED <br /> — 115 �o y <br /> JOB ADDRESS Cho CITY/ZIP �"' rn <br /> CROSS STREET r1i1'14Ct1'f 111- \ AP ,�p PARCEL SIZE �'`' LA USE APPLICATION# v <br /> OWNER NAME G �/ Irl/+ / r l�.L V P�f� `- V- '-2 I vyi <br /> (o 14 <br /> � �(]� [� O ( /fir' m <br /> OWNER ADDRESS lf� ��La �/jw 7 CITY/STATE ZIP ` J vv Cr <br /> CONTRACTOR _ +� � d trl ��r ( y PHONE / -a Va o --4 <br /> IV'Ue S <br /> CONTRACTOR ADDRESS 5y �A w �� CITY/STATE/ IP � � y5 3 v <br /> SUBCONTRACTOR/CONSULTANT ,y / 'A\/( 1 `PHONE <br /> �(/�� ,y <br /> SUBCONTRACTOR/CONSULTANT ADDRESS ,Y 1 1 ' CITY/STATE/ZIP lY <br /> LICENSE _ C-57 XC-61 _ D-09 LI Other NUMBER b" EXPIRATION DA 31,122 (71 <br /> (BILLING PARTY: -OWNER CONTRACTOR -1 SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WEL S PILING: ❑General Mineral/Coliform Bacteria (4391) - Dibromochloropropane(4392)❑ Arsenic(4393) <br /> INTENDED USE _ Domestic/Private !-I Irrigation/Agricultural ._ Industrial _ Water Quality Monitoring _ Soil Sampling/Characterization <br /> _ Public Water System CCC UUU <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK _ New Well a Replacement Well u Well Alteration/Modification _j Other <br /> 1 - Monitoring Well(s) #of wells F1 Soil Boring(s) #of borings - Geotechnical #of borings <br /> _ Out-Of-Service Well a ut-Of-Service Well Renewal a Cross-Connection Repair J1 <br /> - New Pum ❑ Pum Replacement Pum Repair C Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method _ Mud Rotary a Air Rotary a Auger _ Cable Tool L Push Point Other <br /> Proposed Well Depth ft Excavation in diameter ! Open Bottom I_ Gravel Pack/Gravel Size in diameter <br /> _ Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_ in Thickness/Gauge/ASTM Sched _j Steel Li Plastic _ Stainless Steel u Other <br /> Grout Seal Depth ft n Neat Cement(94 lb bag/5-10 gal water) Fl Sand Cement sack mix/7 gal water n <br /> - Bentonite(20%solids) -1 Other f nw <br /> Grout Placement Method - Pumped Fl Free Fall Fl Other Fl Retardant/Accelerator(name) W <br /> PEDESTAL Installed By = Driller ❑ Pump Contractor C Other C <br /> Concrete Pedestal uDimensions:Width ft 11h..th ft Thick in _ Christy Box a Stove Pipe <br /> PUMP ubmersible- Turbine n 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 /> .fOAQU!N CCUN!TY 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 GUNWLiANCE WITH FILL <br /> WORKERS COMPENSATION LAWS. <br /> MINIMt1M 48 HdUR ADVANCE NOTICE REQUIRED FO INS�PECTIIONNSS -PLEASE CALL (209) 953-7697 <br /> SIGNED TITLEy / UnY/ <br /> DATEI? <br /> � a v <br /> I <br /> V <br /> t <br /> 1 C � <br /> S R N -- <br /> NE <br /> DEPARTMENT JUSE ONLY (— <br /> Application Accepted By yL Date t/�6�.� Area S gel Employee ID# r <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> J /� -" <br /> Pump Inspection By rnn t:lc O l.�A-�:� ' DateZ('Z�DL( I WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC ReceivedChec Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B Cash Remitted Service Re est# <br /> �a C <br /> EHD 43-06 6/11/2019 WELL/PUMP PERMIT <br />