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NON-REFUNDABLE PERMIT www.sjgov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS /0 77 ,:t' /42- CITY/ZIP -/ItYfrye) <br />CROSS STREET k("2---GF APN D 0 3 —/‘6, -3 r PARCEL SIZE 39( , LAND USE APPLICATION # <br />OWNER NAME ..7-I ---' A 'Zi5e PHONE (0204 ) 74.'9 7,09Z <br />OWNER ADDRESS ,t- CITY/STATE/ZIP AeSI77,29. I44- 9 s zz?-) <br />CONTRACTOR /14'1 0M:41c /?,./1-7;2 17Lote- PHONE Y 5 7-3z/o <br />CITY/STATE/ZIP ..F/X",e. /(4- 5--7—,5 <br />PHONE <br />CONTRACTOR ADDRESS <br />SUBCONTRACTOR/CONSULTANT <br />SUBCONTRACTOR/CONSULTANT ADDRESS CITY/STATE/ZIP <br />LICENSE fr C-57 /V C-61 E D-09 0 Other NUMBER EXPIRATION DATE <br />BILLING PARTY: I OWNER 11 CONTRACTOR SUBCONTRACTOR/CONSULTANT <br />MIN <br />SIGNED <br />4vs <br />vo 40'1 livee0 <br />z <br />eilitY/41/00 ri)e. WELL/PUMP PERMIT <br />SAN jOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 -6232 (209) 468-3420 <br />DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391)11 Dibromochloropropane (4392) Arsenic (4393) <br /> <br />INTENDED USE Atomestic/Private 0 Irrigation/Agricultural E Industrial CI Water Quality Monitoring E Soil Sampling/Characterization <br />Public Water System <br />If different from Owner: Water System Name Contact Name or Phone Number <br />TYPE OF WORK E New Well 0 Replacement Well 0 Well Alteration/Modification E Other <br />f borings <br /> <br />E Monitoring Well(s) # of wells E Soil Boring(s) # o 0 Geotechnical <br />Out-Of-Service Well C Out-Of-Service Well Renewal E Cross-Connection Repair <br />New Pump /Pump Replacement 0 Pump Repair 0 Raise Well Casing <br />WELL CONSTRUCTION i <br />Drilling Method II Mud Rotary II Air Rotary E Auger E Cable Tool E Push Point C Other <br />Proposed Well Depth ft Excavation in diameter E Open Bottom E Gravel Pack/Gravel Size in diameter <br />Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched 0 Steel 0 Plastic 0 Stainless Steel 171 Other <br />Grout Seal Depth ft E Neat Cement (94 lb bag/5-10 gal water) E Sand Cement sack mix/7 gal water <br />Bentonite (20% solids) 0 Other <br /># of borings <br />Grout Placement Method E Pumped 0 Free Fall El Other E Retardant / Accelerator (name) <br /> <br />PEDESTAL Installed By 0 Driller 0 Pump Contractor LI Other <br />Concrete Pedestal 0 Dimensions: Width ft Length ft Thick in E Christy Box 0 Stove Pipe <br /> <br />PUMP <br /> AfSubmersible 0 Turbine E Other HP Pump Set ft Standing Water Level <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 1MTH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATION LAWS. <br />NCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7691' <br /> DATE 5/Z0 -Z7 TITLE :SS3210C1V 3116 PAYM ENT <br />RECE IVED <br />MAY 2 820 21 <br />N COL N <br />ENVIRON MENTAL <br />HEALTH OEPAI3TM <br />,J11 <br />SA7\1JOAQU, TV <br />it <br />DEPARTMENT USE ONLY <br />Application Accepted By ---- /- Z--- Date <br />Date <br />Pump Inspection By <br />Grout Inspection By Ate_ <br />owiv,01jyriet7 Date <br />Soil Boring Inspection By Date <br />COMMENTS <br />2-02( <br />Area Veiel Employee ID# A. <br />SPECIAL Well Permit <br />II WAIVER Received <br />Constructed Well Depth ft <br />PE <br />Codes <br />Li? !1 <br />SC <br />Info <br />Received <br />B ..._ 4e01600 Amount <br />Remitted Date Permit/ <br />Service FeAu_est <br />IlATOOttl <br />r Invoice # Well ID# Cash <br />0&-0 4 , , - --)67 47 ? 511-512-4 <br />EHD 43-06 6/11/2019 WELL /PUMP PERMIT