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WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT <br />CALL 209) 953-7697 FOR INSPECTIONS <br />EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS C) � 17S � r j- ,-1 , <br />/� <br />` I C" n lo- K CITYIZIP !\C <br />61 0 PC) ` 9 5 :� 3(1) <br />CROSS STREET�1 1 I P I C V� <br />)) PARCEL SIZE tI <br />S7 AP`1N U C'5 '-;?70 <br />LAND USE # <br />//)Z <br />/1 <br />``f <br />t� <br />'APPLICATION <br />t/ /C1 <br />—(1� �1 —C��SO (Gy <br />OWNER NAME I1 -e I t K -I lO <br />I '� L/1 1 j ' ✓� r0 u s <br />PHONE / <br />OWNER ADDRESS 7 C/7 S LSI mt <br />I L q I-,rS w CITY/STATE/ZIP <br />1 <br />C2,1 I+ r\ �` I l� J <br />CONTRACTOR \' 1 ') I, 1-,P �—`�) I '--t <br />\ s Y) C4 <br />PHONE <br />CONTRACTOR ADDRESS G � G X <br />I CIN/STATE/ZIP <br />1 I r C- A C715 <br />SUBCONTRACTOR <br />_ <br />PHONE <br />SUBCONTRACTOR ADDRESS <br />CITY/STATE/ZIP <br />LICENSE -57 C-61 D-09 <br />ZZ <br />Other NUMBER t�c� J .> <br />"7 <br />EXPIRATION DATE / _ z <br />DOMESTIC WELL SAMPLING:,( General Mineral/Coliform Bacteria (4391)( Dibromochloropropane (4392) Arsenic (4393) <br />INTENDED USE )CDomesfic/Private Inigation/Agricultural Industrial Water Quality Monitoring r` Soil Sampling/Charactenzation <br />Public Water System <br />If different from Owner. Water System Name Contact Name or Phone Number <br />TYPE OF WORK '>CNew Well Replacement Well D Well Alteration/Modification Other <br />D Monitoring Well(s) # of wells ❑ Soil Boring(s) # 01 borings Geotechnical # of bonngs <br />D Out -Of -Service Well ❑ Out -Of -Service Well Renewal Cross -Connection Repair <br />`;?(New Pump Pump Replacement 0 Pump Repair Raise Well Casing <br />Drilling Method)< Mud Rotary Air Rotary Auger Cable Tool Push Point Other <br />Proposed Well Depth ft Excavation I ? in diameter ❑ Open Bottom )(Gravel Pack/Gravel Size 1/q - in diameter <br />C caily i woiiiciei r COT6'ai:111 ucpui <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched C -I � ' Steel >.Plastic Stainless Steel Other <br />Grout Seal Depth )C'O ft Neat Cement (94 Ib bag/5-10 gal water) K Sand Cement 1 sack mix/7 gal water <br />Bentonite (20% solids) Other <br />Grout Placement MethodK Pumped Free Fall Other Retardant 1 Accelerator (name) <br />PEDESTAL Installed By X Driller D Pump Contractor Other <br />Concrete Pedestal Dimensions: Width 2 ft Length ft Thick n Christy Box Stove Pipe <br />PUMP 'GSubmersible Turbine Other HP _ 3 Pump Set=5_ ft Standing Water Level 1 -7�5 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 />MINIMUM 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />v l / DEPARTMENT USE ONLY <br />Application Accepted By T — L�� Date 4/'?' <br />I <br />Grout Inspection By : i .V ;<� t04. <br />ift�pl -Il_ Date ti9- <br />Pump Inspection By kro:L -Lb, , L-ov`t t4s'.- Date <br />WIY 72 s <br />Soil Boring Inspection By <br />COMMENTS <br />L'C;tl !�! <br />A <br />Area employee Di —' 7 <br />SPECIAL Well Permit F���EA1 <br />WAIVER Received �® <br />Date Constructed Well Depth® �ft <br />�.,,. 02 <br />iry ✓nn <br />AI .. /te <br />EHD 43-06 revised 4/14/19 WELL /PUMP PERMIT <br />2®2, <br />CpUN <br />NTA( �' <br />TMFNT <br />t <br />EHD 43-06 revised 4/14/19 WELL /PUMP PERMIT <br />2®2, <br />CpUN <br />NTA( �' <br />TMFNT <br />