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ki <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE -STOCKTON CA 95205 -6232 (209) 468-3420 <br />IVVIV-Mtl•UNUAhSLt PERMIT www.sjgov.org/eiid <br />JOB ADDRESS A�V_ 91?7 a 0_r Zv*1 <br />CROSS STREET 4rv4 APN�j C L C),S-- <br />p <br />OWNER NAME � AX Ile,/ <br />OWNER ADDRESS <br />CONTRACTOR <br />CONTRACTOR ADDRESS <br />SUBCONTRACTOR/CONSULTANT L <br />SUBCONTRACTOR/CONSULTANT ADDRESS <br />LICENSE -'�6­C-57 ❑ C-61 ❑ D-09 <br />BILLING PARTY: ❑ OWNER <br />i <br />7f ' <br />�/zeSS ter! � <br />1 YEAR FROM DATE ISSUED <br />CITY/ZIP 40E/1 <br />SIZE LAND USE APPLICATION #j <br />PHONE T/0–S` C ` --0/I <br />DI <br />CITY/STATE/ZIP <br />PHHOONEE 23 f1- <br />CITY/STATE/ZIP <br />PHONE 3 17– <br />CITY/STATE/ZIP <br />❑ Other NUMBER 3/ 360-r EXPIRATION DATE O Z� <br />>ONTRACTOR ❑ SUBCONTRACTOR/CONSULTANT <br />DOMESTIC WELL SAMPLING: ❑ General Mineral/Coliform Bacteria (4391) ❑ Dibromochloropropane (4392) ❑ Arsenic (4393) <br />NTENDED USE ornestic/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 eNew Well 36 RP.nIaCP.nnlP.nt WPII ❑ WPII Alteration/Mnrlificatinn n nthar <br />❑ Monitoring Well(s) # of wells ❑ Soil Boring(s) # of borings ❑ Geotechnical <br />❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />ia:flew Pump ❑ Pump Replacement ❑ Pumo Repair ❑ Raise Well Casino <br /># of borings <br />Drilling Method -?<Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other <br />Proposed Well Depth. '�O ft Excavation ,/2-' in diameter ❑ Open Bottom YGravel Pack/Gravel Size in diameter <br />❑ Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter A in Thickness/Gauge/ASTM Sched ❑ Steel .► plastic ❑ Stainle s Steel ❑ Other <br />Grout Seal Depth 12U ft ❑ Neat Cement (94 /b bag/5-10 gal water) and Cement , sack mW7 gal water <br />❑ Bentonite (20% solids) ❑ Other <br />Grout Placement Method Pumped ❑ Free Fall ❑ Other ❑ Retardant / Accelerator (name) <br />PEDESTAL Installed By 5211riller ❑ Pump Contractor ❑ Other <br />❑ Concrete P destal ❑Dimensions: Width ft Length = ft Thic in ❑ Christy Box ❑ Stove Pipe <br />PUMP i<ubmersibie❑ Turbine ❑ Other HP 3 Pump Set ft Standing Water Level 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,HO�UJF ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209)) 953-7697 <br />SIGNED TITLE DATE <br />DEPARTMENT USE ONLY <br />Application Accepted By—/� L L Date <br />Grout Inspection By _I^.:iLCiSj v n H7- Date 5jZZ21j � <br />Pump Inspection By 3 r"'t o Cry Date <br />Soil Boring Inspection By Date <br />COMMENTS EJrlsf(v1i, v\)el) -to rer✓I neo. /dote Cord fi,)n of Pel <br />T <br />m <br />D <br />0 <br />0 <br />m <br />cn <br />En <br />Area I q rl Employee ID# <br />❑ SPECIAL Well Permit !Y <br />F <br />❑ WAIVER Received iv o,. <br />Constructed Well Depth L�?1 <br />,n _,,]I <br />PE <br />Codes <br />SC Received Check <br />Info B ash <br />Amount Permit/ <br />Remitted Da Service Request # Invoice # Well ID# MEiI <br />y3�J <br />OS 1 <br />)sa Il 21 <br />+)378 <br />1$O <br />,gypWko 4�5 � y <br />LI31-4) <br />4)so cf It <br />I I <br />EHD 43-06 6/11/2019 WELL /PUMP PERMIT <br />