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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 />IVVIY-KLFUNUABLEPERMIT \ t W1NW.S O <br />Ov.r/ena 1 hAVIK1=5 11 YEAR FROM DATE ISSUED <br />JOB ADDRESS 13 S L O h ) -e C I 'L' `! j� 1/ 'l CITYZP�n1 /I, �• 1 1 G I C� �t "1 <br />CROSS STREET W „t Yl CI 6 r1 I` D APN j OS 1 Oil PARCEL SIZE f ✓Iv' � ND USE APPLICATIIrO"NuN # <br />OWNER NAME) PHONE'( <br />ADDRESS <br />CITY/STATEMP <br />VGII1,e� Dr ',1tt '(� �I <br />PHONE <br />.. .Xj — <br />�? / -79 <br />ADDRESS C )� (- 4 <br />CIN/STATE/ZIP Lr � 1� <br />r <br />C' 5 <br />'OR/CONSULTANT <br />PHONE <br />1, <br />� L IL)3e,1 <br />SUBCONTRACTOR/CONSULTANT ADDRESS <br />LICENSE -AC-57 C-61 D-09 <br />BILLING PARTY: OWNER <br />CITY/STATE/71P <br />Other NUMBER _I GI 3 D3 EXPIRATION DATE U 3 t f V` <br />II SUBCONTRACTOR/CONSULTANT <br />DOMESTIC WELL SAMPLING:x General Mineral/Coliform Bacteria (4391)y(Dibromochloropropane (4392) Arsenic (4393) <br />INTENDED USE pC Domestic/Private Imgation/Agricultural - Industrial G 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 ANew Well Replacement Well Well Alteration/Modification Other <br />D Monitoring Well(s) # of wells Soil Bonng(s) # or borings Geotechnical # of bonngs <br />❑ Out -Of -Service Well Out -Of -Service Well Renewal i Cross -Connection Repair <br />Drilling Method �b1ud Rotary Air Rotary -- Auger Cable Tool Push Point Other <br />Proposed Well Depth JC J it Excavation in diameter Open Bottom )( Gravel Pack/Gravel Size 14 -- in diameter <br />i Conductor Casing in diameter / Conductor Casing Depth it <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched ( !i;C Steel 4,Plastic Stainless Steel Other <br />Grout Seal Depth it, i ft Neat Cement (94 lb bag/5-10 gal water) �y{ Sand Cement 1 C .7 sack mix/7 gal water <br />Bentonite (20% solids) L Other <br />Grout Placement Method APumped I Free Fall Other _ Retardant / Accelerator (name) <br />PEDESTAL Installed By l9LDriller ❑ Pump Contractor n Other <br />Concrete PedestaliDlmensions: Width 3 ft Length j ft Thick C in i 1 Christy Box Stove Pipe <br />PUMP Submersible_. Turbine Other HP 3 Pump Set_L' 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 />MINIMUM 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PL1EASE\ CALL (209) 953-7697 <br />SIGNED 16, lT LLt/: ' TITLE `' <br />_�� ! f C S I C1 lei' DATE <br />DEPARTMENT USE ONLY t <br />Application Accepted By � L— Date I I VpZO I <br />Area y �/ / Employee ID# <br />Grout Inspection By Date � SPECIAL Well Permit <br />Pump Inspection By Date Z0 WAIVER Received <br />Soil Boring Inspection By. Date Constructed Well Depth ft <br />COMMENTS P'Grtrj u!e,,.Jers1iLZ ni l� <br />SPc.liTcy�1P Il. � r�i irlPli 7° `PY/f� !r. .�-� <r' Jt' Yeslc=/r:�CE <br />PE <br />Codes <br />SC Received Check#/ <br />B <br />Info Cash <br />Amount Date <br />Remitted <br />Permltl Invoice # Well ID# <br />Service Re uest# <br />3 <br />t,` I <br />lif <br />�!M- <br />1, <br />� L IL)3e,1 <br />LA I LA 'A <br />L13 C•,� <br />EH043-06 6/11/2019 WELL/PLMP PERMIT <br />rA <br />