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WELL/PUMP PERMIT <br />SAN JOAQUIN CouNTr ENWiommENTAL HEALTH DEPARTMENT 1868 EAST HAzELTON AVENUE - STOCKTON CA 9520$ - (209) 468)420 <br />NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS y� ^ �EX�P�IpR�ES 1 YEAR FROM DATE ISSUED <br />JoeADDREasQ�D Crrr(LPj1V1Q.I,Fi%raJ (-A 9533 7 <br />CROSS STREET UK �, 1 !, � APN LL-�— QUO—ND PARCEL SRE - /k LAND U9E�APrPn�❑nuCATIONiI�i1i Q(� G� <br />OWNER NAME Wf+1 ON N /P,H 1ONE y/]t/ 1(.'(j��vQl ar' --/1 <br />OWNER ADDRESS 1 1 V I J (/ CrTY/STAT110P N&lA1�J{PJLJtJI . CJl/FV� �-% 1�/1�.�t�� 7fry/ <br />CONTRACTOR wrk1S Y I I114q V PHONE ` -1 nC J'Li(�I�1 (��—t)7 <br />CONTRACTOR ADDRESS 1 1 CfTYISTATEILP W GW q.0 I <br />SUBCONTRACTOR PHONE <br />SUBCONTRA`rTTOR ADDRESS CRYISTATrMp <br />UCEN6E `7p C-57 D C-61 ❑ D-09 D Other NuNi9ER A ExPIRATON DATE %). <br />DoMesnc WELL SAMPUNG:)IfGeneral FAnerat/Coliform' Bacteria (4391 )Dibromochloropropane (4392) 0 Arsenic (4393) <br />INTENDED Use 6omesticJPrtvate 0 IRigabon/Agrlculturel D Industrial 0 Water Quality Monitoring 0 Soil Sampling/Characterization <br />0 Public Water System <br />It dMarent from Owner. Water System Nuns Contact Name or Phone Number <br />Tire OF WORK 0 New Well Replacement Well 0 Wen Alleration/ModiOcatton 0 Other <br />❑ Monftoring Wei (s) 9 of wells 0 Soil Bodng(s) a er b"Inge ❑ Geotechnical a o1 bO l 9' <br />0 Out -Of -Service Well 0 Out -Of -Service Well Renewal 0 Cross -Connection Repair <br />❑ New Pump ❑ Pump Replacement ❑ Pump Re alr 0 Raise Well Casing <br />WEE,L CON3T11UCTION <br />Drilling Method Mud Rota ❑ Air Rotary 0 Auger D Cable Toot D Push Polnl D Other <br />Proposed Well Depth T it Eccava0on 1-1,- In diameter D Open Bottom ❑ Gravel Pack/Gravel Size In diameter <br />0 Cond o Casing In diameter / Con d r asing Depth ft <br />Well Casing Diameter. In Thickness/Gauge/ASTM Schad ❑ Steel Plastic 0 Stainless Steel 0 Other <br />Grout Seal D plh ft 0 Neat Cement (94 Ib bag/540 gel water) ❑ Send Cement sack mix/7 gel water <br />Banlonite (20% solids) ❑Other <br />Grout Placement Method 4 Pumped 0 Free Fell 0 Other ❑ Retardant / Accelerator (name) <br />PEDESTAL Installed By ❑ Driller 0 Pump Contractor ❑ Other <br />D Concrete Pedestal ODlmenslons: Width R Length ft Thick in 0 Christy Box D Stove Plpe <br />PUMP 0 Submerslble0 Turbine 0 Other HP _ Pump Set ft Standing Water Level It <br />I HEREBY CERTIFY THAT 1 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 - PLEASE CALL (209) 953-7697 <br />C NT <br />IVSD <br />D <br />04 2021 <br />NITDOENP4 <br />Ulhr COU <br />LENTA�TY <br />PARTMENT <br />_ DEPARTMENT USE ONLY <br />^�? Application Accepted By pate '�) Area C <br />Employee IDB D/ <br />L <br />Grout Inspection By Date ❑ SPECIAL Well Permit <br />Pump Inspection By Date ❑ WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth ft <br />COMMENTS <br />rr+D+Sae tvovta 7 9 <br />WELL /PUMP PERMR <br />rNAM <br />rr+D+Sae tvovta 7 9 <br />WELL /PUMP PERMR <br />