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t f <br /> WELL/PUMP PERMIT <br /> I SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232(209)468-3420 <br /> NON-REFUNDABLE PERMIT/���J� �.„`n y�—WWW.s ov.or /ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS L 1Lk1 <7dAw��l` ✓r • CIN/ZIP �T V V 1 !0(s)-09 y <br /> m <br /> CROSS STREET -Thomas UP11Y1 M�r,71 LOAr M APN A070—-1140-7W PARCELSIZE C "IA LAND USE APPLI/C�ATION# A <br /> 4- OWNER NAME 1'llo�VLQa� R G�I g LOL (M�,�1141'Cr PHONE�y�W ipt /' c a,+ <br /> IOto2 Grey► 10.c1)�.' v, CITYI$TATE21P "� • f Cx �"' <br /> OWNER ADDRESS ►'` �/�(� /� (1/� <br /> lVr S CONTRACTOR V W l PHONE(f�/r'1� 1 V 3�7 100 <br /> CONTRACTOR ADDRESS T �l �]t CITY/STATE/ZIP GaI4 I CA I gSro-3L <br /> (Q t�� SUBCONTRACTOR/CONSULTANT WALI&IiP - Vdial 4 PISIOCAG<�l F��PH/O�NE (p9'l16`)3�.��2-1w4/� /u�'C(Q <br /> SUBCONTRACTOR/CONSULTANT ADDRESS 30AV 1%ld"hi-Irial lblvd.CITY/STATE/ZIP w W4- S acrW�'W��O+0/00 1 Ute+ l.) <br /> LICENSE I/C-57 0 C-61 0 D-09 0 Other /� NUMBER 120%4 ExPIRATION DATE 41301 211 <br /> BILLING PARTY: ❑OWNER EI CONTRACTOR f17 SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING:❑General Mineral/Coliform Bacteria(4391)D Dibromochloropropane(4392)0 Arsenic(4393) <br /> INTENDED USE D Domestic/Private 0 Irrigation/Agricultural 0 Industrial D Water Quality Monitoring eSoil Sampling/Characterization <br /> D Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK ❑New Well 0 Replacement Well 0 Well Alteration/Modification 0 Other <br /> ❑Monitoring Well(s) #of wells D Soil Boring(s) #of borings tjAeotechnical L1 4 of borings <br /> 0 Out-Of-Service Well 0 Out-Of-Service Well Renewal 0 Cross-Connection Repair <br /> D New Pum 0 Pump Replacement ❑Pump Repair 0 Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method 0 Mud Rotary 0 Air Rotary VAuger 0 Cable Tool L Push Point 0 Other <br /> Proposed Well Depth10 Mft Excavation �O in diameter D Open Bottom ❑Gravel Pack/Gravel Size in diameter <br /> 0 Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Schad D Steel 0 Plastic ❑Stainless Steel 0 Other <br /> Grout Seal Depth 10 ft Aeat Cement(94 lb bag/5-10 gal water) D Sand Cement sack mixf7 gal water <br /> ❑Bentonite(20%solids) 0 Other IF,ii <br /> Grout Placement Method 0 Pumped BSFree Fall Otheretar an ccelerator(name) <br /> PEDESTAL Installed By D Driller 0 Pump Contractor ❑ Other <br /> ❑Concrete Pedestal❑Dimensions:Width ft Length ft Thick in 0 Christy Box D Stove Pipe <br /> PUMP 0 Submersible Turbine 0 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 /> MIN U 4ADVANCE NOTICE REQUIRED FOR IN�\SPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED TITLE <br /> ' S F-- go-DATE <br /> 111fi 1111 111111 1111 11111 1111 <br /> PAYMENT <br /> DECEIVE© <br /> CIO <br /> UG 12 2021 <br /> LAM J-1-MVIRONMENTAL <br /> OAQUIN COUNTY <br /> TH DEPARTMENT <br /> DEPARTMENT .SfE ONLY ,s}trk Y1 <br /> Application Accepted By�R Z Date d Area Employee ID#A <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection Date �( Constructed Well Depth ft <br /> COMMENTS�Gi er {bfA pP11Al S WPOO'fa�O GNc.� ►�Paotlao7C1. <br /> PE SC Received Check#/ Amount Permit/Codes Info Cash Remitted ate 144-lice Re uest# Invoice# Well ID# <br /> a to 57-7- <br /> 0001 <br /> I <br /> i <br /> EHD43-M 6/11r1019 ^� WELL/PUMP PERMIT <br /> AU% 9* <br />