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w <br />WELL/PUMP PERMIT -7 % J J <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1866 EAST HAZELTON AVENUE - STOCKTON CA 95205 -6232 (209) 468-342 <br />NON-REFUNDAB E ERMIT .S .O /ehd EXPIRES 1 YEAR FROM PA <br />TE ISSUED <br />JOB ADDRESS Ll D ti�+` I v a Kof CiTyrzt. Cd I CA <br />I �` C.11 U <br />CROSS STREETt ri f' AA�PN O O f I PARCEL SIZE 0 rte"•' LAND USE gVpZ LIGX�ATIOON # <br />OWNER NAME t LA `^ I • . 1 PHONE <br />OWNER ADDRESS <br />CONTRACTOR `I , <br />CONTRACTOR ADDRESS <br />PHONE <br />CITYISrA P [�/,�n S <br />SUBCONTRACTOR/CONSULTANT &/ / ✓ PHONE <br />SUBCONTRACTOR/CONSULTANT ADDRESS I-A.r/C{ITY/STATE/7jP <br />LICENSE C-57 -kC-61D-09 `^' <br />XOther NUMBER^P VEXPIRATIDN <br />BILLING PARTY: OWNER / \ CONTRACTOR SUBCONTRACTOWCONSULTANT <br />NiMMI1111111111111116 <br />DOMESTIC WEyAMPUNG: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic (4393) <br />INTENDED USE Domestic/Private Irrigation/Agricultural Industrial Water Quality Monitoring Soil Sampling/Characterization <br />Public Water System <br />If different from Owner. Water System Name Contact Name or Phone Number <br />TYPE OF WORK New Well Replacement Well Well Alteration/Modification Other <br />Monitoring Well(s) # of wells Soil Borings) u of bon"gs Geotechnical p of borings <br />2t-Of-Servic.2 /Well Out -Of -Service Well Renewal Cross -Connection Repair <br />o,...... Y o......, o....i.............. -- o......:. 0-- rnren r.,��.... <br />WELL CONSTRUCTION <br />Drilling Method Mud Rotary Air Rotary Auger Cable Tool Push Point Other <br />Proposed Well Depth ft Excavation in diameter Open Bottom Gravel Pack/Gravel Size in diameter <br />Conductor Casing in diameter / Conductor Casing Depth It <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Sched Steel Plastic Stainless Steel Other <br />Grout Seal Depth ft Neat Cement (94 lb bag/5-10 gal water) Sand Cement sack mix/7 gal water <br />Bentonite (20% solids) Other <br />Grout Placement Method Pumped Free Fall Other Retardant / Accelerator (name) <br />PEDESTAL Installed By Driller Pump Contractor Other <br />Concrete Pedestal Dimensions: Width ft Lengtht ft Thick r in Christy Box §1ove Pipe, <br />PUMP x Submersible Turbine Other HP t Pump Setj V ft Standing Water Level C 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 MUM 48 HOUR DVA TICE REQUIRED FO� PECTIION�S/- PLEASE CALL (209) 97 <br />SIGNED TITLE W VLAJIY 1 4 DATE <br />J DEPART <br />Application Accepted By <br />Grout Inspection By <br />Pump Inspection By <br />Soil Boring Inspection By <br />COMMENTS <br />MENT USE ONLY <br />Date elioh 1 <br />Date <br />Date <br />Date <br />c C� <br />Area � � � EmployeelD#�_ <br />SPECIAL Well Permit <br />WAIVER Received <br />Constructed Well Depth tY <br />VV <br />c <br />NT <br />'ED <br />10 2021 <br />QUIN COUNTY <br />ONMENTAL <br />DSPARTMENT <br />EHD 4&O6 6/11/2019 WELL /PUMP PERMIT <br />MM <br />1&XJAWiW 31E. 4§ I s-EJ011WErJ'�— <br />11111111111111111111111111,---_ <br />EHD 4&O6 6/11/2019 WELL /PUMP PERMIT <br />