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i <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 -6232 (209) 468-3420 <br />NUN-KEFUNDABLE VERMII <br />WWW.SICIOV.O <br />JOB ADDRESS S�,e IC Bi j Loo CITY/ZIP &_111_611C -G T S /VIP �J <br />CROSS STREET /�<�</Zj APN �� <br />O PARCEL SIZX4/. LAND USE APPLICATION <br />## <br />(?H- 57 - <br />OWNER NAME &sPHONE <br />OWNER ADDRESS 4)WIrl CITY/TATE/ZIP /A <br />CONTRACTOR `1i� PHONE :?:TV <br />CONTRACTOR ADDRESS 179 � <br />CITY/STATE/ZIP <br />SUBCONTRACTOR/CONSULTANT <br />SUBCONTRA``C__TOR/CONSULTANT ADDRESS <br />LICENSE br<57 D C-61 ❑ D-09 ❑ Other <br />BILLING PARTY: OWNER ',CONTRACTOR <br />CITY/STATE/ZIP_ <br />NUMBER 3'h3,C <br />SUBCONTRACTOR/CONSULTANT <br />PHONE <br />EXPIRATION DATE <br />DOMEsTtc WELL SAMPLING: General Mineral/Coliform Bacteria (4391) I Dibromochloropropane (4392) Arsenic (4393) <br />INTENDED USE ❑ Domestic/Private rrigation/Agricultural ❑ Industrial 0 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 >rqq ew Well ❑ Replacement Well D Well Alteration/Modification ❑ Other <br />0 Monitoring Well(s) # of wells D Soil Boring(s) # of borings ❑ Geotechnical # of borings <br />❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal D Cross -Connection Repair <br />>f4ew Pump ❑ PumD Reolacement ❑ PumD Repair D Raise Well Casino <br />WELL CONSTRUCTION <br />Drilling MethodMud Rotary D Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point 0 Other <br />Proposer) Well Depth �� ft Excavation in diameter D Open Bottom X-, ravel Pack/Gravel Size in diameter <br />❑ Conduc Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameters in Thickness/Gauge/ASTM Sched 6_ D Steel Plastic ❑ Stainless Steel ❑ Other, <br />Grout Seal Depth J e ft D Neat Cement (94 lb bag/5-10 gal water) � p Sand Cement �� J sack mix17 gal water <br />❑ Bentonite (20% solids) 11 Other <br />7` <br />Grout Placement Method 5eumped ❑ Free Fall ❑ Other D Retardant / Accelerator (name) <br />PEDESTAL Installed By )2°DDriller ❑ Pump Contractor D Other <br />D Concrete Pedestal ❑Dimensions: Width a ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe <br />PUMP ubmersible❑ 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 COMPENSATION LAWS. <br />MINIMUM 48 HOU DVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-76697 <br />SIGNED _�— TITLE DATE DATE 6l Z F— I p <br />- <br />Application Accepted By <br />Grout Inspection By <br />Pump Inspection By <br />Soil Boring <br />COMMENTS <br />(�Z Employee ID# <br />SPECIAL Well Permit <br />WAIVER Received <br />m <br />0 <br />0 <br />v <br />m <br />En <br />PE SC Received <2EtecW Amount Date <br />Codes MO Gash Remitted <br />Permit/ <br />Service Request # <br />Invoice # Well ID# <br />__BV <br />12.2•Iq <br />VJP SD <br />2.2.1 °l <br />00 0 S <br />EHD43-06 6/11/2019 WELL /PUMP PERMIT <br />