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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 /> NON-REFUNDABLE PERMIT www.sjgov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> p(] m <br /> Joe ADDRESS O-I \,j 1 L)CY)c r )Z V CITY/Z1P LU<_� <br /> D <br /> CROSS STREET� v�� �� n APN O' S�,_PARCEL SIZE `�C_LAND USE APPLICATION 7Y p <br /> ) { � <br /> 1 7 J / �1 m <br /> OWNER NAME IJl'/e 4t, 'r /C� t1 Ke S:C1r p (e —5`�Sep VI 7 I(V e t.) PHONE <br /> OWNER ADDRESS 1 l�'C �,I 1-re 1? I 1�1 1) C., ) L't' CITYISTATEZP 4 1 n <br /> CONTRACTOR rte,I C 1 r )` r �I PHONE 7C/"'�� — -- t �/1 l <br /> CONTRACTOR ADDRESS C' X CITY/STATEZP %�'' ) ` � ` 1 5 4' S.Jt <br /> SUBCONTRACTOR/CONSULTANT PHONE <br /> SUBCONTRACTOR/CONSULTANT ADDRESS CITYISTATEIZIP �7 Z 3 { _ �`�} <br /> LICENSE A C-57 C-61 D-09 L. Other NUMBER 2LI"I J S 5 EXPIRATION DATE / - ` <br /> BILLING PARTY: OWNER XCONTRACTOR SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING:/,General Mineral/Coliform Bacteria(4391)N'Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE Domestic/Private Irrigation/Agricultural Industrial Water Quality Monitoring ❑ Soil Sampling/Charactenzation <br /> _:Public Water System <br /> If different fiom Owner Water System Name Contact Name or Phoria Nu"be, <br /> TYPE OF WORK Y-New Well Replacement Well i i Well Alteration/Modification ❑Other <br /> Monitoring Well(s) S of wells -:Soil Bodng(s) a elb"n"' 0 Geotechnical a of borings <br /> Out-Of-Service Well -Out-Of-Service Well Renewal IJ Cross-Connection Repair <br /> New Pump a Pump Replacement Pump Repair ❑Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary !Air Rotary Auger Cable Tool Push Point J Other <br /> Proposed Well Depth 30S Excavation in diameter -.Open Bottom >�Gravel Pack/Gravei Size 1/4_ in diameter <br /> Conductor�Casing in diameter / Conductor Casing Depth tt <br /> Well Casing Diameter in Thickness/Gauge/ASTM Schad C -?LO` l7 Steel )4 Plastic Stainless Steel Other <br /> -t <br /> Grout Seal Depth 242C _ft [_Neat Cement(94 lb bag/5-10 gal water) >�Sand Cement IC S sack mix17 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method XPumped Free Fell ❑Other t:Retardant/Accelerator(name) <br /> PEDESTAL Installed By X Driller C Pump Contractor Other <br /> Concrete Pedestal_;Dimensions:Width_�__ft Length f ft Thick in Christy Box -1 Stove Pipe <br /> PUMP )0%Submersible'",Turbine 'Other HP�� Pump Set�_tt 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 /> ;LtIN1,IUM 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-t PLEASE CALL(209)953-X7'769 <br /> SIGNEDl'✓•r�Jlt+� TITLE �I t ��t rS C.1 r'Y1 4 DATE <br /> �J <br /> LJ <br /> L' <br /> C, <br /> '@F Y�E�'T <br /> EC <br /> 5 o l QU/N CO <br /> 01 <br /> DEPARTMENT USE PNLY <br /> Application Accepted By Date 1r1 Employee ID# <br /> Grout Inspection By Det. 2 ZO� J-1SPECIALWell Permit <br /> Pump Inspection By Date >a WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE Sc Received Check#I Amount PermlU <br /> Codes Info B Cash Remitted Date Service Re uesttM Invoice# Well <br /> I3c�Z70 l <br /> EHO 43-06 6/112019 WELL/PUMP PERMI' <br /> �� � /�7203/b7 <br />