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A• WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 -6232 (209) 468-3420 <br />NON -REFUND PEW% r1 ,r ov.oP 1ehd , EXPIRES I YEAR FRQ DATE ISSUED <br />'v 1Vd <br />JOB ADDRESS .4 u (� Crr.. v/ � 1 L <br />CROSS STREET AN <br />O AAPN � r V PARCEL SIZE AN E AP��Pyt)"CATION # r/ 1/ <br />OWNER NAME j(' /���y/��,/�/�� HOG ✓ V <br />OWNERADDRESS V�vlp�J{L�`� • L �/� �% C CIT/pY/' T T9 / �\ <br />CONTRACTOR ! �iJT"' , ✓ " / ^• L4 r • `, /J ./ :LYLIC.' A.. (� PHONE <br />CONTRACTOR ADDRESS v ! l ��. (ll CITY/S A Y . �A I I� <br />SUBCONTRACTOR/CONSULTANTt v 1 4PHONE <br />SUBCONTRACTOR/CONSULTANT ADDRESS ITY/STATEIZIP Il� <br />X % <br />LICENSE C-57 � \ C-61 D-09 Othe G./1% NUMB��(IMRA <br />BILLING PARTY: OWNER v CONTRACTOR SUBCONTRACTOR/CONSULTANT <br />V <br />DOMESTIC WEL lm <br />PUNG: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic (4393) <br />FL-ENDEDUSE omestic/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 />MonitoringWell(s) —# of wells SoilBoring(s) #of borings Geotechnical #ofbonngs <br />Out-Of-Servi ell Out -Of -Service Well Renewal Cross -Connection Repair <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 ft <br />Well Casing Diameter _ in Thickness/Gauge/ASTM SchedSteel Plastic Stainless Steel Other <br />Grout Seal Depth ft Neat Cement (94 lb bag15-10 gal water Sand Cement sack mixf7 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 />oncrete Pedestal Dimensions: Width ft Le t ft Thick n Christy Box Stove Pipe <br />PUMP Submersible Turbine Other HP Pump Set ft Standing Water Level ft <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THA THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br />JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULA ONS. 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 FqW INSPECTIONS - PLEASE CALL (209 95 7697 <br />SIGNED TITLE !/fes. rn rj f/1 DATE `�' <br />Application Accepted By �—%LyL Date 7!/ <br />Grout Inspection By Date <br />Pump Inspection By Date V1 <br />Soil Boring Inspection By III, Date <br />COMMENTS <br />Area 1 Employee ID#L0�c <br />SPECIAL Well Permit DR <br />WAIVER Received <br />Constructed Well Depth <br />MR �ti7r.\ ® ... .. <br />L�1 • I�%�i'�`i/AE�7r7%7��!!'�IR�Il1I�11��C�� <br />EHD 43-06 6/11/2019 WELL /PUMP PERMIT <br />rn <br />i4 <br />