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Date <br />Date <br />Date <br />Date <br />SO\ VI-01A <br />( <br /> <br />Application Accepted By <br /> <br />Grout Inspection By <br /> <br />Pump Inspection By <br /> <br />Soil Boring Inspection By <br />COMMENTS <br />Area Lliqei <br />. <br /> <br />Employee ID# (17 <br />SPECIAL Well Permit <br />WAIVER Received <br />Constructed Well Depth 'CT) ft <br />012101 , <br />.3i›Z WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 -6232 (209) 468-3420 <br />www.siaov.ora/ehd EXPIRES 1 YEAR FROM DATE ISSUED - -• 7,....---6 - - .-- • n <br />JOB ADDRESS <br />...7 <br />o l'" w e r e r tckm..., ciTy/zip cc4 ((so (--cf c/53ZA-2 „ =, <br />CROSS STREET E 5 (414 3 0 - E.e II0)-6, APN ddet 0 8036 PARCEL SIZE 1 ' ° (.. LAND USE APPLICATION # <br />g a x <br />1 1 - m <br />(an-fe/bi-€ F3 g--- OWNER NAMEIMC) ‘ J t a n r rrt PHONE 2 01)2 / <br />OWNER ADDRESS2 Z glitereit t_a rt...si.....,.., CITY/STATEIES C a /6 //I Co (353 -to c _,.....:La <br />E 502 9 -c(i2 (7 CONTRACTOR 2-7 (dC{ 6 frrl" PIA 1141AS <br />C pt .. <br />CONTRACTOR ADDRESS 5-(J ci 1-2-A- Iii, <br />u offi c_in pHo <br /> te--101 crryisTATErrp - - CO q-535 0 r <br />SUBCONTRACTOR/CONSULTANT hi 111 PHONE V On Q <br />A/ 149 <br />SUBCONTRACTOR/CONSULTANT ADDRESS ki (19 , ... c5TY/STATE/ZIP <br />LICENSE C-57 C-61 0-09 L Other 0 Z' NUMBER 1 (.9 6 CO D EXPIRATION DATE IL( 3 1 12,022. _ ,,.\( _ - ..4 <br />BILLING PARTY: OWNER X CONTRACTOR 7 SUBCONTRACTOR/CONSULTANT <br />DOMESTIC WELL SAMPLING: 0 General Mineral/Coliform Bacteria (4391) 1 Dibromochloropropane (4392) 0 Arsenic (4393) <br />No <br />INTENDED USE Domestic/Private U Irrigation/Agricultural _ Industrial _ Water Quality Monitoring _ Soil Sampling/Characterization „X <br />Public Water System _ <br />If different from Owner: Water System Name Contact Name or Phone Number <br />TYPE OF WORK New Well U Replacement Well Li Well Alteration/Modification = Other _ c <br />- Monitoring Well(s) # of wells n Soil Boring(s) # of borings - GeotechnicalpAym# of borings <br />_ Out-Of-Servici, - I Li Out-Of-Service Well Renewal UCross-Connection RepaiRL-, ENT <br />= New Purn. Pump Replacement D Pump Repair C Raise Well Casing <br />r <br />WELL CONSTRUCTION c .. <br />Drilling Method Mud Rotary LI Air Rotary L Auger Cable Tool = Push Point Other 111AR 2 3 2021 _ _ _ r- <br />Proposed Well Depth ft Excavation in diameter J Open Bottom L Gravel P&VOmeiAz,e in diameter <br />Conductor Casing in diameter / Conductor Casing Depth ENV/i wc-JIN COLJN „ _ ft <br />HEALTH C'EADNMENT — ' Well Casing Diameter in Thickness/Gauge/ASTM Sched J Steel LI Plastic _ Stainless Steelp , <br />Grout Seal Depth ft n Neat Cement (94 lb bag/5-10 gal water) n Sand Cement sack rz41x17 gal water .,. <br />= Bentonite (20% solids) A Other <br />Grout Placement Method - Pumped n Free Fall n Other 5 Retardant / Accelerator (name) <br />1PEDESTAL Installed By 1 Driller 0 Pump Contractor C Other <br />Concrete Pedestal UDimensions: Width ft Length ft Thick in _ Christy Box LI Stove Pipe , _ <br />1(9 CI Turbine n Other HP / Pump Set 0 ft Standing Water Level 0 ft PUMP doN Submersible - <br />I HEREBY CERTIFY THAT I HAVE <br />JOAQUIN COUNTY ORDINANCE <br />CURRENT AND ACTIVE WITH THE <br />WORKERS COMPENSATION LA <br />rin , 48 HOU ' <br />0 <br />S. <br />. DV <br />PREPARED <br />STATE <br />THIS APPLICATION <br />LAWS, AND RULES AND <br />IFORNIA CONTRACTORS <br />NCE • TICE REQUIRED <br />AND THAT THE WORK WILL BE DONE IN ACCORDANCE <br />REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED <br />STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE <br />FTIsISPECTIONS - PLEASE CALL (209) 953-7697 <br />vt te nq ciA/---- DATE 3114 <br />WITH SAN <br />LICENSE IS <br />WITH ALL <br />12„/ SIGNED , TITLE <br />/ i <br />, <br />1 4 L -... <br />\ <br />04 <br />C <br />1 \AtCAA <br /> 1 11 <br />u t I I I I II III I I I <br />.1 <br />1 1 1 1 1 I 1 1 1 1 1 1 1 <br />DEPARTMENT USE ONLY <br />PE <br />Codes <br />SC <br />Info B <br />Receivedtewcglir.)4/ Amount <br />Remitted Da e Permit/ <br />Service Request # Invoice # Well ID# <br />q .31 os-0 (1&, - 3/E3Z .f 77 '9.- IA 10004-1Si <br />EHD 43-06 6/11/2019 <br />WELL /PUMP PERMIT