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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205.6232 (209)468-3420 <br /> • NON-REFUNDABLE PERMIT www.sjgov.org/ohd EXPIRES 1 YEAR FROM DATE ISSUED <br /> _ ��33� a <br /> -73 _y <br /> Joe ADDRESS 5- CO S• C ht,41,5/i'J AN �,V CITY/ZIP / QlACLi 61L <br /> CROSS STREET 6ty,r '(2d APN / 'Z PARCEL SIZE _LAND US" <br /> OWNER <br /> # p v <br /> OWNER NAME AL/ l�,r� S�yy��' T6- <br /> CONTRACTOR <br /> OWNER ADDRESS /9�/�! c lA�,ft'L' �"-"���`f CITYISTATE/ZIP //- <br /> CONTRACTOR (�A-A,,-,OX �I /�'� /Nom' <br /> CONTRACTOR ADDRESS 7:7117 ✓C-SI0- c - CITY/STATE/ZIP <br /> SUBCONTRACTOR/CONSULTANT PHONE <br /> SUBCONTRACTORICONSULTANT ADDRESS CIN/STATE/ZIP 7 <br /> LICENSE ((C-57 D C-61 ❑D-09 D Other NUMBER 02 [ 77ZIJI ExPIRATION DATE -131 ,7'- — <br /> BILLING PARTY: 0 OWNER CONTRACTOR C SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING:❑General Mineral/Coliform Bacteria(4391)0 Dibromochloropropane(4392)0 Arsenic(4393) <br /> INTENDED USE D Domestic/Private Irrigation/Agricultural ❑Industrial 0 Water Quality Monitoring D 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 0 Replacement Well ❑Well Alteration/Modification C Other <br /> D Monitoring Well(s) #of wells D Soil Boring(s) #of borings D Geotechnical #of borings <br /> D Out-Of-Service Well D Out-Of-Service Well Renewal Cross-Connection Repair <br /> D New Pump G Pump Replacement D Pump Repair ❑Raise Well asin <br /> WELL CONSTRUCTION <br /> Drilling Method D Mud Rotary D Air Rotary Cl Auger C Cable Tool C Push Point ❑ Other ✓� S ull �J <br /> Proposed Well Depth It Excavation in diameter D Open Bottom D Gravel Pack/Gravel Size -in diameter <br /> D Conductor Casing�—in diameter / Conductor Casing Depth �5—e It <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched #;a -a A Steel ❑ Plastic ❑Stainless Steel ❑Other <br /> Grout Seal Depth_ ft D Neat Cement(941b bag/5-10al water) &c Sand Cemen�J D°° 3 sack mix/7 gal water <br /> ❑Benrunne Izv ro solids) C Other <br /> Grout Placement Method A Pumped D Free Fall D Other D Retardant/Accelerator(name) <br /> PEDESTAL Installed By 0 Driller ❑Pump Contractor ❑ Other <br /> D Concrete Pedestal❑Dimenslons:Width ft Length ft Thick in 0 Christy Box 0 Stove Pipe <br /> PUMP DSubmersible❑Turbine C Other HP Pump Set ft Standing Water Level ft <br /> 1 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 CO PENSATION LAWS. <br /> MI UM 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)95 -769 <br /> SIGNED /rL� TITLE // � DATE <br /> t <br /> j <br /> A4Y <br /> lie" I <br /> CO <br /> A(/ <br /> THI p�pgRNT CNTY <br /> i I 4fe <br /> iT TP - <br /> `� DEPARTMENT USE ONLY <br /> NAL,,t1 O DL Application Accepted By F Date 1Y Area Employee ID# <br /> M 1 r <br /> Y. 0' Grout Inspection By /tL i Date "t 11q= SPECIAL Well Permit <br /> per( . r / <br /> 1 i e i t)T�0 ,L J Pump Inspection By _ Date_ ❑ WAIVER Received qAF <br /> C�n mel Soil Boring Ins action By Date Constructed Well Depth ft �OI(U' <br /> Vi \ COMMENTS (' 'T til 1 -O i l T 1'c (' TC: / CT(iC' I <br /> ra N( Y O 1 !' L+ ' <br /> b(L4�)Ji� <br /> PE Sc Received Che Amount Dat Permit/ Invoice# Well ID# fl F vJ e I►. <br /> Codes Info ash Remitted S ry ce Request# <br /> �43tr) 0 Mqj <br /> EHD 43-06 6/112019 WELL/PUMP PERMIT <br />