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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 <br />1NWW.5i v.org/ehd <br />EXPIRES 1 YEAR FROM DATE ISSUED <br />�l <br />A <br />JOB ADDRESS <br />CITY2IP <br />�`(V� <br />9`300( d , ' ' <br />USE AP�O]N # <br />CROSS STREET O A <br />APN PARCEL SIZE <br />LAND �7 <br />A <br />OWNER NAME i� ,r.j� <br />r \ <br />ho y- 'v Qs I _-_-_._-____ <br />IPLICATI� <br />PHONE I / y S3 11 <br />N <br />OWNER ADDRESS CmY/STATE/ZIP <br />CONTRACTOR <br />1 G3 PHONE <br />�'� F— Qt Q <br />CONTRACTOR ADDRESS 3oa ' I �� CtTY/STATE2IP�V r 10-k C a - lS ` <br />SUBCONTRACTOR/CONSULTANT PHONE <br />SUBCONTRACTOR/CONSULTANT ADDRESS �CrrY//STT/ATE21Pc1 <br />LICENSE -Ae C-57 C-61 D-09 Other NUMBER l -7 1 -a' d/ EXPIRATION DATES 3 ` <br />BILLING PARTY: OWNER CONTRACTOR SUBCONTRACTOR/CONSULTANT <br />DOMESTIC WELL SAMPLING; General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic (4393) <br />INTENDED USE hrpomesticiPrivate Irrigation/Agricultural Industrial Water Quality Monitoring Soil Sampling/Characterization <br />Public Water System <br />If differert from 0- Water System Name Contact Name or Pnone Number <br />TYPE OF WORK New Well Replacement Well I Well Alteration/Modification Other <br />Monitoring Well(s) # of wells Soil Bonng(s) ° of obong' Geotechnical # of oorrgs <br />Out -Of -Service Well Out -Of -Service Well Renewal Cross -Connection Repair <br />WELL CONSTRUCTION <br />Drilling Method ), Mud Rotary Air Rotary Auger M Cable Toot Push Point Other <br />Proposed Well Depth a,4R Excavation III in diameter Open Bottom(Gravel Pack/Gravel Size�fl in diameter <br />Condugtor Casing �� in diameter / Conductor Casing Depth N � ` It <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched S Lk D - Steel Plastic Stainless Steel Other <br />Grout Seal Depth 'ZX�C) it Neat Cement (94 lb bag15-10 gal water) Sand Cement sack mix/7 gal water <br />-;Q Bentonite (20% solids) Other <br />Grout Placement Method�ped Free Fall Other Retardant / Accelerator (name) <br />PEDESTAL Installed By Driller Pump Contractor Other <br />Concrete Pedestal DimensionsWidth ft Length ft Thick in Christy Box Stove Pipe <br />PUMP Submersible 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 CO SATION LAWS. <br />M1 M 48 H1WJJRRAADVANCE NOTICE REQUIRED FO INSPECTIONS . PLEASE CALL (209)) 953-7697 <br />SIGNED J "4 —� TITLE�� t- r J o DATE <br />EFNT <br />QED <br />102020 <br />(MEN7-AL <br />'ARTMENT <br />7 - <br />DEPARTMENT UONLY <br />Application Accepted By �/— Date <br />Grout Inspection By Date <br />Pump Inspection By Date <br />Soil Boring Inspection By 1j.. Date d <br />COMMENTS <br />Area �/ `/ Employee ID# <br />SPECIAL Well Permit <br />WAIVER Received <br />Constructed Well Depth ft <br />PAI <br />EHO 41-06 6112019 WELL HUMP PERMIT <br />