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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 i WVUVV.Sj' Ov.Or /ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS ! Y3 7 is ld~,q CITYIZIP N �\ <br /> m _�t <br /> CROs ST^hEET Liv/�(;/l(/[t`� p �I 5-002—pN ® pgRCEL 512E_k, <br /> LAND SE APPLICATION# O <br /> OWNER NAME <br /> N <br /> OWNER ADDRESS PHONE� /T�j CITY/STATE/ZIP S'CONTRACTOR I \20.5 1/�S M� PHONE J /�1+•+( <br /> CONTRACTOR ADDRESS r/ J�!/O� CIN/STATE/ZIP 442A& <br /> /14t <br /> SUBCONTRACTOR/CONSULTANT •��J'Y%) (nhfSL'f �J <br /> PHONE <br /> SU13CONTRACTORICONSULTANT ADDRESS yCITY/STATEIZIP <br /> d <br /> LICENSE 91,-57 0 C-61 ❑D-09 D Other NUMBERS 7T.�- EXPIRATION DATE to <br /> BILLING PARTY: 0 OWNER �•ONTRACTOR ❑SUBCONTRACTORICONSULTANT <br /> DOMESTIC WELL SAMPLING:0 General Mineral/Coliform Bacteria(4391)D Dibromochloropropane(4392)D Arsenic(4393) <br /> INTENDED USE Domestic/Private ❑Irrigation/Agricultural 0 Industrial 0 Water Quality Monitoring 0 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 New Well 0 Replacement Well IT <br /> Alteration/Modification ❑Other <br /> 0 Monitoring Wells) #of wells ❑Soil Boring(s) #of borings 0 Geotechnical #or borings <br /> 0 Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> ew Pump 0 Pump Replacement ❑Pump Repair 0 Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method)WMud!RR�'7otary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑ Other- <br /> Proposed Well Depth -1� ft Excavation_/7— In diameter 0 Open Bottom sirGravel Pack/Gravel Size in diameter <br /> 0 Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_f� in Thickness/Gauge/ASTM Schad Z-D":, 0 Steel Plastic ❑Stainless Steel 0 Other <br /> Grout Seal Depth 1,7J It 0 Neat Cement(94/b bag/5-10 gat water) 'Sand Cement `f, '3 sack mix/7 gal water <br /> 0 Bentonite(20%solids) 0 Other <br /> Grout Placement Method P Pumped 0 Free Fall 0 Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By >00riller 0 Pump Contractor ❑ Other <br /> ❑Concrete Pedestal❑Dimensions:Width ft Length ft Thick in 0 Christy Box 0 Stove Pipe <br /> PUMP ;Zeiubmersible0 Turbine ❑Other HP 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 /> MINI�.cc.�'� HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)`953-7697 <br /> SIGNED TITLE 01Gj1C*1_ DATE la- <br /> Lf <br /> ( <br /> G <br /> P M <br /> � P <br /> DE ARTMENT USE0 LY <br /> Application Accepted By _ Date LZ C�Z I Area I ` Employee ID# <br /> Grout Inspection By C/•^ Date S ❑ SPECIAL Well Permit <br /> Pump Inspection By Date D WAIVER Received(DJ <br /> Soil Boring Inspection By Date Constructed Well Depthrft <br /> COMMENTS <br /> PE SC Received Check#/ Amount DatePermit/ Invoice# Well ID# <br /> Codes Info 'Cash Remitted Seryuest# <br /> b(7 ISO 19,01 1+20 <br /> 1 Z <br /> at <br /> O IS <br /> 4 <br /> Y <br /> EHD43-06 6/11/2018 WELL/PUMP PERMIT <br />