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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMW <br />1868 EAST HAzrLTON AVENUE - STOCKTON CA 95205 -6232 (209) 468-3420ELL/PUMP PERMIT <br />NON-REFUNDABLE PERMIT WWW-sOv.O[/ehd <br />EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS <br />h r crrvrz,P Lo SZ LI 1 0 <br />CROSS STREET APN'J <br />l �.Y PARCEL SIZE D <br />LAND USE APPLICATION # <br />OWNER NAME, y m <br />PHONE <br />T �D�- <br />OWNERAODRESS I Q� N. �e�`iy ,�n �I �q <br />_ I 1^ RJV! Y 1 CITY/STATEZP /j�� t q5 L�b <br />CONTRACTOR 00 a�`� 1 , )CI 1p � (� m C I CI <br />�7 � " � �/V `�`.' � t,-fi� L I IC.I PHONE �D� <br />CONTRACTOR ADDRESS _Z 12-0 W ( l Cox �,' �f� /����C jq <br />CITY($TATEZP_ J CA 9 JGZ' <br />SUBCONTRACTOR/CONSULTANT <br />PHONE <br />SUBCONTRACTOR/CONSULTANT ADDRESS <br />CITYISTATEZP__ <br />LICENSE I -C-57 = C-61 D-09 _ Other(9 <br />NUMBER EXPIRATION DATE J Z <br />BILLING PARTY; � OWNER <br />-CON TRACTOR SUBCONTRACTOR/CONSULTANT <br />DOMESnc WELL SAMPLING: a General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) = Arsenic (4393) <br />INTENDED USE �Qomestic1Private - Irrigation/Agricultural - Industrial - Water QualityMonitorin <br />Public Water System 9 Soil Sampling/Characle talion <br />Ilditlerent from Owner Water System Name <br />Contact Name or Phone Number <br />TYPE OF WORK -- New Well - Replacement Well _ Well Alteration/Modification <br />Other <br />Monitoring Well(s) # of wells Soil Boring(s) s of borings <br />OUt-Of-Service Well= Geotechnical _I If borings <br />New Pump <br />Out -Of -Service Well Renewal Cross -Connection Repair <br />_ Pump Replacement = Pumn Pe it - _. ..... _ <br />Drilling Method Mud Rotary Air Rotary _ Auger Cable Tool _ Push Point <br />Proposed Well Depth ft Other <br />Excavation in diameter Open Bottom Gravel Pack/Gravel Size <br />Conductor Casing in diameter / Conductor Casing Depth ft in diameter <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Sched <br />Grout Seal Depth ft Steel Neal Cement (941b Plastic - Stainless Steel Other <br />bag/5-10 gal wale/) Sand Cement <br />Bentonite (20% solids) _: Other sack mix/7 gal water <br />3rout Placement Method _ Pumped Free Fall _: Other <br />Retardant /Accelerator (name) <br />�EOESTAL Installed By Duller =Pump Contractor -- Other <br />me <br />Concrete Pedestal =Dinsions: Width ft Length R Thick <br />n = Christy Box - Stove Pipe <br />SUMP Submersible _ Turbine - Other <br />H.P. a Set �' a alanamg water Level If <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATIOAND 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 />WORKrRS COMPENSATION,,AWq. <br />Application Accepted By <br />Grout Inspection By <br />Pump Inspection By <br />Soil Boring Inspection By <br />COMMENTS j l-� •fit <br />ARTMENT USE OZA LY <br />Date <br />Date <br />Date <br />Date <br />CALL (2139' 2 -''El- <br />DATE <br />��'� <br />Area Employee ID# <br />Ci SPECIAL Well Permit <br />WAIVER Received <br />Constructed Well Depth ft <br />F ���NT <br />CE <br />/VP® <br />EHD 33-03 6/11/2019 <br />VrLL IPU1: P PER&!!; <br />1� 1 �FMT <br />