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i <br /> 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 M".sjgov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS l 6 CIN/LP <br /> r' D <br /> h •�0 9LAND USE APPLICATION# A <br /> CROSS STREET APNy S OC ®p��j PARCEL SIZI <br /> '�Q m <br /> O'VOWNER NAME V O PHON _ 2 ^W 0? <br /> OWNER ADDRESS / Z # CITY/STATE/ZIP,,-MXrAP IZ, <br /> Z4172- <br /> CONTRACTOR <br /> CONTRACTOR r'Lx SS �`/y/ f PHONE A3 r` 417 <br /> CONTRACTOR ADDRESS Z�7y/J CIN/STATEIZIP /z <br /> SUBCONTRACTOR/CONSULTANT �/(-4-t�'� -% PHONE , <br /> SUBCONTRACTORICONSULTANT ADDRESS CITY//STATEIZIP <br /> LICENSE )<C-57-57 D C-61 0 D-09 ��❑��Other NUMBER 7,273-et' <br /> /7TE <br /> 3a r EXPIRATION DATE Z� <br /> BILLING PARTY: D OWNER �/C''.ONTRACTOR 0 SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING:0 General Mineral/Coliform Bacteria(4391)0 Dibromochloropropane(4392)0 Arsenic(4393) <br /> INTENDED USE Dornestic(Prlvate 0 Inigation/Agricultural 0 Industrial 0 Water Quality Monitoring D Soil Sampling/Characterization <br /> 0 Public Water System <br /> If different from Owner. Water System Name Contact Name or Phone Number _ <br /> TYPE OF WORK-,-dNew Well 0 Replacement Well 0 Well Alteration/Modification 0 Other <br /> 0 Monitoring Well(s) #of wells O Soil Boring(s) #of borings D Geotechnical #of borings <br /> D Out-Of-Service Well 0 Out-Of--Service Well Renewal 0 Cross-Connection Repair <br /> ew Pump 0 Pump Replacement ❑Pump Repair ❑Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Metho&4 Mud Rotary D Air Rotary 0 Auger ❑Cable Tool 0 Push Point ❑ Oth�/V-er- <br /> Proposed Well Depm3_ft Excavation in diameter 0 Open Bottom Gravel Pack/Gravel Size in diameter <br /> 0 Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diamet in Thickness/Gauge/ASTM Sched 7 2O Steel �ePlastic ❑Stainle Steel 0 Other <br /> Grout Seal Depth O ft 0 Neat Cement(94 Ib bag/5.10 gal wate4 )eSand Cement sack m1x/7 gal water <br /> 0 Bentonite(20%solids) 0 Other <br /> Grout Placement Method,)9�Pump&d 0 Free Fall D Other 0 Retardant/Accelerator(name) <br /> PEDESTAL Installed BYX Driller 0 Pump Contractor ❑ Other <br /> ❑Concrete Pedestal❑Dimensions:Width ft Length ft Thick in 0 Christy Box D Stove Pipe <br /> PUMP >4ubmersIbleD Turbine 0 Other HP_2,,_ Pump Set ft Standing Water Level It <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 COMPENSATION LAWS. <br /> MINIMUMM 44 HO R ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7.6y9.7/ <br /> SIGNED JIMW � TITLE(/�T/ �' DATEIF <br /> r <br /> Htt— <br /> D <br /> N p <br /> E 7 <br /> DEPARTMENT USE ONLY ' (���JjNT <br /> Application Accepted By Date 9 d Area ? C Employee ID# f lZ <br /> Grout Inspection By ��r-i Date ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COM ME TS .tf sj Il I c; h O e ✓ o r, 'liZ41 yt <br /> PE SC Receive ec Amount Date PermiU Invoice# Well ID# <br /> Codes Info B Remitted Service Re uest# <br /> q376 190 ( P <br /> H 3_1 I O tl 1 <br /> a OS' <br /> EHD 43-06 61112018 WELL/PUMP PERMIT <br />