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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 Ar www.sjgov.org/ehd I EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS -4 V a ! CITYIZIP Z14C A%' q <br />CROSS STREET _ a * �^ <br />APN O071q D d L PARCEL SIZSq. LI LAND USE APPLICATION #_ <br />OWNER NAME e ` eA4 a ! i+ l i 6 {3GI o -TT,:4e PHONE e5;�7F-q73_7 <br />OWNER ADDRESS <br />CITY/STATE/ZIP <br />CONTRACTOR _r] OL -/f (�jnG.�•S� !PHONE-35/L?-� <br />CONTRACTOR ADDRESS _45b��1�/� CITY/STATE/ZIP_ &"I"404AA, a <br />SUBCONTRACTORICONSULTANT (L J G.(1'/+1 PHONE C `r 2'27 <br />SUBCONTRACTOR/CONSULTANT ADDRESS <br />LICENSE ,2eC-57 ❑ C-61 ❑ D-09 ❑ Other <br />BILLING PARTY: I OWNER _jeONTI <br />CITY/STATE/ZIP _ <br />NUMBERS 1''13Rp EXPIRATION DATE C-13 <br />13 <br />SUBCONTRACTOR/CONSULTANT <br />DOMESTIC WELL SAMPLING,: I I General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) L : Arsenic (4393) <br />INTENDED USE omeslic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization <br />rl Public Water System <br />If different from Owner: Water System Name Contact Name or Phone Number <br />TYPE OF WORK >lew Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other <br />I -I Monitoring Well(s) # of wells ❑ Soil Boring(s) # of borings <br />Geotechnical # of borings <br />❑ Out -Of -Service Well CI Out -Of -Service Well Renewal CI Cross -Connection Repair <br />sAew Pump ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method>41vIud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other <br />Proposed Well Depth -3 SO ft Excavation ZL in diameter ❑ Open Bottom >69fravel Pack/Gravel Size in diameter <br />❑ Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter d—o in Thickness/Gauge/ASTM Sched7 a� ❑ Steel X&Iastic ❑ Stainless SWW ❑ Other <br />Grout Seal Depth–Ie-0 ❑Neat Cement (94 Ib bag/5 10 gal water) Mand Cement G�/ sack mix/7 gal water <br />❑ Bentonite (20% solids) ❑ Other <br />Grout Placement Method ACIPumped ❑ Free Fall ❑ Other CI Retardant / Accelerator (name) <br />PEDESTAL Installed By A<riller ❑ Pump Contractor ❑ Other <br />❑ Concrete Pedestal C1Dlmensions: Width . q_ ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe <br />f PUMP )eubmersible❑ Turbine ❑ Other HP Pump Set_ it Standing Water Level it <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAI' 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 />MINIMU 48 HOUR VANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209))7-/1,-V <br />953-7697, / <br />SIGNED--- "� c! TITLE_.(.AfAV LL '- l DATE -/L- Y <br />r� <br />D <br />0 <br />0 <br />U) <br />DEPARTMENT USE ONLY <br />Application Accepted By L_ ,Z_ —. Date 7 19 a 1 <br />Grout Inspection By _ _ Date <br />Pump Inspection By M Date —�_ <br />Soil Boring Inspection By <br />COMMENTS E31S141! <br />Date <br />J <br />Area tFmployee ID# Fn <br />SPECIAL Well Permit <br />_,1W WAIVER Received <br />, Constructed Well Depth 319X <br />ft <br />PE <br />Codes <br />SC Received <br />Imo A BY <br />Check#I AmountPermit/ <br />C Remitted Date <br />(< <br />ervice Request # Invoice # Well ID# <br />378 <br />l-1 ao •2W0014,7VM <br />y3ga <br />li,�?;] <br />2 <br />L3 0 <br />- s <br />EHD 43-06 6/11/2019 , W • i WELL /PUMP PERMIT <br />