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1 <br />G�Lz��D <br />SAN JOAQUIN COUNTY ENVIRONME HEALTH MIT /-�AST HAZELTON AVENUE - STOCKTON CA 95205 6232 (209) 468-3420 ( <br />NON-REFUNDABLE PERMIT AL DEPARTMENT WELL/PUMP PER 1868 E <br />- LVWW.gOV.OrNlehd <br />IJos ADDRESS �,� /�jj�/II ) Q i�XPIRES 1 YEAR FROM DATE ISSUED <br />- — - CITY/Zip _ l�VLXKI J U-4 / X/45 <br />CROSS STREET APN fi0. '7 (� �S- <br />OWNER NAMEX 1 PARCEL SIZE f f LAND USE APPLICATION <br />� #/� p r <br />� (U J <br />OWNER ADDRESS 1� ( PHONE (�� / <br />CONTRACTOR _ <br />CITYISTATEIZIP_ �3y s <br />l � 7 �] / <br />CONTRACTOR ADDRESS a{ PHONE!��-7^y� <br />CITY/STATEfZIP <br />SUBCONTRACTOR/CONSULTANT A 11 <br />PHONE <br />SUBCONTRACTOR/CONSULTANT ADDRESS <br />C TY/STATE/ZIP <br />LICENSE57 C-61 D-09 <br />J Other NUMBER EXPIRATION DATE <br />BILLING PAJ _OWNER <br />CONTRACTOR SUBCONTRACTOR/CONSULTANT <br />DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic (4393) <br />INTENDED USE DOmestIC/Private _ Irrigation/Agricultural -Industrial -Water Quality Monitoring Soil SamplinglCharacterization <br />- Public Water System <br />V different from Owner. Water System Name <br />Contact Name or Phone Numher <br />TYPE OF WORK - New Well -- Replacement Well Well Alteration/Modification <br />Other <br />Monitoring Well(S) # of wells Soil Boring(s) # of borings <br />J Out -Of -Service bell Geolechnical # of bmings <br />q Out -Of -Service Well Renewal = Cross-ConneCtion Repair <br />New Pump Pump Replacement Pump Repair <br />FELL Co�sTRucnoN Raise Well Casing <br />oNNIng 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 n diameter <br />LGroutP <br />ing Diameter _ in Thickness/Gauge/ASTM Sched <br />eal Depth Steel _Plastic Stainless Steel Other <br />P ft Neat Cement (94 Ib bag/5-10 gal water) Sand Cement <br />Benlonite (20% solids) -: Other sack mixq gal Water <br />ement Method Pumped Free Fall Other <br />= Retardant/Accelerator(name) <br />PEDESTAL Installed By Driller - Pump Contractor - Other <br />Concrete Pedestal ._:Dimensions: Width ft Length R Thick <br />n - Christy Box :- Stove Pipe <br />PUMP Submersible : Turbine - Other <br />P Pump Sel it Standing Water Level fl <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 />E�N/OTTIICE REQUIRED FOR IN /ECTIOOJNS - PLEASE CALL (209) 95 76" <br />TITLEG �j/L G� "� <br />DATE <br />7 DEPARTMENT USE ONLY <br />Application Accepted By � " L Dale 1 <br />Grout inspection By Date <br />Pump Inspection By / Date ( C, <br />Soil Boring Inspection By <br />COMMENTS <br />Date <br />I� Y !!iii F. N <br />ECSVE D <br />4 2021 <br />JOAQUIN COUNTY <br />WIRONMENTAL <br />LTH DEPARTMENT <br />Area Lj CA C <br />Employee ID# i • I I �< C' <br />SPECIAL Well Permit <br />-- WAIVER Received <br />Constructed Well Depth ft <br />`l/cLL IPUPAP PER7.11T <br />