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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/ehd EX IRES 11 YEAR FROM DATE ISSUED <br /> JOB ADDRESS V I� t� I ' CITY/ZIP C�,•f A <br /> M <br /> /� h (� m <br /> CROSS STREET v v 4 A NJ U�t+ `��c S PARCEL SIZE LAND USEPARCEL # O <br /> OWNER NAME ;O -x N� ( C /t > PHONE V � LoATION 777/ <br /> OWNER ADDRESS /` 141 �/ CITY/STATE/ZIP <br /> CONTRACTOR G^-OrJe� VUJL 0 PHONES 33 7�. <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP �C/�a r <br /> �J <br /> SUBCONTRACTOR/CONSULTANT Gil PHONE Z/ �-3 Z Z D <br /> SUBCONTRACTOR/CONSULTANT ADDRESS CITY/STATE/ZIP <br /> LICENSE pAC-57 ElC-61 E, D-09 L1Other NUMBER 2:7;7.W f EXPIRATION DATE (5-- <br /> BILLING PARTY: 1 OWNER PO!WONTRACTOR SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING X General Mineral/Coliform Bacteria (4391) Dibromochloropropane(4392) ❑Arsenic(4393) <br /> INTENDED USE Domestic/Private ❑ Irrigation/Agricultural C 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 ew Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other <br /> ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings ❑ Geotechnical #of borings <br /> ❑ Of-Service Well ❑ Out-Of-Service Well Renewal 11Cross-Connection Repair <br /> 4� Pump C Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method >4ud Rot C Air Rotary Li Auger ❑ Cable Tool F] Push Point 11 Other <br /> Proposed Well DepthzWft Excavation in diameter ❑ Open Bottom ravel Pack/Gravel Size in diameter <br /> ❑ Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_61 in Thickness/Gauge/ASTM Sched 90 Steel KPlastic ❑ Stainless Steel ❑ Other <br /> Grout Seal Depth /CIO ft 11 Neat Cement(94 Ib bag/5-10 gal water) 5)8and Cement �/047 sack mix/7 gal water <br /> ❑ Bentonite(20%solids) ❑ Other <br /> Grout Placement Method umped ❑ Free Fall ❑ Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By riller ❑ Pump Contractor ��L Other <br /> Ll Concrete Pedestal []Dimensions:Width 7 ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe <br /> PUMP Ng'ubmersibleii 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��/[�S HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br /> SIGNED /�• TITLE D KJ/w k DATE 6 — <br /> L92 L <br /> cz <br /> e <br /> IT <br /> Epim <br /> h EA_TF DE PA RTf9E T <br /> I C3 <br /> DEPARTMENT USE ONLY <br /> Application Accepted By �— �L— L- Date %/a y Area ! ( Employee ID# � <br /> Grout Inspection By Ir Date ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER ReceiV d <br /> Soil Boring Inspection By Date Constructed Well Depth U Q <br /> 5 ft <br /> COMMENT <br /> T "k ) i7 /E'/'�C:fl1 Y1 5�!/ c,c ' F�� ' 0 T Se GLIA pc vG� <br /> rofL4Sof � � ),�L�O .UY�4 . �t�L [.a� G1 M✓ S�r'�I �G�"1C >����� LZ <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info A B Cas Remitted Service Request# <br /> 93K) o� ) <br /> s7E o l ydJ <br /> 090L 2 <br /> 1-702_17_j41 q <br /> EHD 43-06 6/11/2019 WELL/PUMP PERMIT <br />