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WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE -STOCKTON CA 95205 -6232 (209) 468.1420 <br />NON-REFUNDABLE 1NWW.s ov.of /ehd EXPIRES I YEAR FROM DATE ISSUED <br />Joe ADDRESS '✓'� 0' i"� F tr�J r `'j / 110P 17'1 U c A 9 S(o3 a <br />CROSS STREET 1 _'�1�(1b r r l y t�� 1/ ./APN 0 �J f v 1 L' PARCEL SIZE � ° � LAND USE APPLICATION # <br />OWNER NAME &bP �'�r- ))(��(�'i 1 1 ` //P\t 5PHONEZV <br />G / <br />OWNER ADDRESS 7' '•\' n�G f `\ r� f� 1 CRlam <br />Y/STATE/ZIP '01 I � 1 C 113 D <br />CONTRACTOR Y) 1 c ,'J[ t I^ ` ) PHONE 3G9 n- 8-779 <br />CONTRACTOR ADDRESS �• Q 1 ri>c q a CITY/STATE/ZIP C C1 <br />SUBCONTRACTORICONSULTANT <br />PHONE <br />SUBCONTRACTOR/CONSULTANT ADDRESS Crry/STATE/LP <br />LICENSE Y C:-57 D C-61 ::: D-09 - Other NUMBER 1"gtl 383 EXPIRATION DATE 7 _3 1 -02 <br />BILLING PARTY: ❑ OWNER CONTRACTOR SUBCONTRACTOR/CONSULTANT <br />DOMESTIC WELL SAMPLING:A General Mineral/Coliform Bacteria (4391)? Dibromochloropropane (4392) -] Arsenic (4393) <br />INTENDeOUSE )(Domestic/Private ❑ Inigabon/Agricultural C Industrial - Water Quality Monitoring :J Soil Sampling/Characterization <br />Public Water System <br />I/ different from Owner: Water System Name Contact Name or Phone Number <br />TYPE OF WORK >CNew Well Replacement Well ❑ Well Alteration/Modification 11Other <br />Monitoring Well(s) # of wells ❑ Soil Boring(S) s olbonngs _ Geotechnical A of borings <br />Out -Of -Service Well f.': Out -Of -Service Well Renewal Cross -Connection Repair <br />rilling Method( Mud Rotary i"- Air Rotary Auger - Cable Tool .. Push Point Other <br />'oposed Well Depth. Excavation Io in diameter Open Bottom !, Gravel Pack/Gravel Size lig - in diameter <br />Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter -G-- in Thickness/Gauge/ASTM SchedC 00 -. Steel X Plastic Stainless Steel Other <br />Grout Seal Depth 100 ft Neat Cement (94 lb bag/5-10 gal water) X Sand Cement 1(} ,3 sack mix(7 gal water <br />11 Bentonite (20% solids) Other <br />rout Placement Method`}; Pumped J Free Fall Other L Retardant / Accelerator (name) <br />PEDESTAL Installed By ><Driller Pump Contractor i Other <br />Concrete Pedestal -Dimensions: Width ft Length ft Thick in Christy Box Stove Pipe <br />PUMP Submersible.7 Turbine L Other HP__5__ Pump Set_ (Q0 ft Standing Water Level iaQ tt <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 1 AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATION LAWS. <br />MINIMUM 488e,, <br />HHflUR, -ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) Q 69 <br />95'3-77 <br />SIGNED Zt''l r TITLE N <f— T`'�S1CICn* DATE D 3 G <br />PACE vl <br />RE <br />AUG I <br />SA ENO RONIME <br />HEALTH DEPA <br />DEPARTMENT USE ONLY <br />Application Accepted By -� Date �ry�'n <br />Grout Inspection By Det: �/ <br />Pump Inspection By 1 "`r '[" . L Date Cj1 l &r I <br />Soil Boring Inspection By <br />Date <br />Area Employee ID# <br />SPECIAL Well Permit <br />C WAIVER Receive 1,' <br />Constructed Well Depth f <br />5S $I-! 4T xl :� <br />PE SC Received <br />Check#/ Amount <br />r <br />Date Partnitl Invoice# WeII1D# <br />Codes Info <br />Cash Remitted <br />Service uestti <br />g F C.; <br />.y' '' <br />I 0)L Z <br />121L <br />4 <br />Wo" C I 10T <br />'s <br />- <br />) . , <br />E11043 -M 6/11/2018 ✓ WELL/PUMP PERMIT <br />