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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 96206-6232(209)468-3420 <br /> NON-REFUNDABLE PERMIT www.sjgov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS y3 �- Y/1 CITY/LP 1 m <br /> CROSS STREET AOld�PN 1 DL)Od7 PARCEL SIZE('/, LAND USE APPLICATION# <br /> OWNER NAME PHONE <br /> �iV/� I�hll/ `�l LL �' <br /> OWNER ADDRESS ��p/ �' CITY/STATE/ZJP <br /> CONTRACTOR/ ��"'�f'£ r"�� / 1 PHONE <br /> 7 <br /> CONTRACTOR ADDRESS � CITY/STATE2IP <br /> G C�•l Rl /LYI` <br /> SUBCONTRACTOR/CONSULTANT T a l �l�"J�-� �i'7^"V�' PHONE <br /> SUBCONTRACTOR/CONSULTANT ADDRESS CITY/STATEIZIP <br /> LICENSE XrC-57 ❑C-61 ❑D-09 ❑Other NUMBER 377 7Dr EXPIRATION DATE <br /> BILLING PARTY: ❑OWNER ❑CONTRACTOR ❑ SUBCONTRACTORICONSULTANT <br /> DOMESTIC WELL SAMPLING:V General Mineral/Coliform Bacteria(4391)A Dibromochloropropane(4392)❑Arsenic(4393) <br /> INTENDED USE xit'Domestic/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 >CNew Well Replacement Well D Well Alteration/Modification ❑Other <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 6q BP k6 <br /> ew Pum ❑Pum Replacement ❑Pum Repair ❑Raise Well CasingA <br /> WELL CONSTRUCTION <br /> SM JOgOUIFU C <br /> Drilling Method "ud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑ Other ..E�IROAIR tie, <br /> Proposed Well Depth 30 ft Excavation t l' in diameter ❑Open Bottom ❑Gravel PacklGravel Size OFPgRrjq peter <br /> ❑Conductor Casing in diameter / Conductor Casing Depth It <br /> Well Casing Diameter 16 in Thickness/Gauge/ASTM Sched ­� ❑Steel .Plastic ❑Stainless Steel i J Other <br /> Grout Seal Dept ?0 it ❑Neat Cement(94 lb bag/5-10 gal water) D-Sand Cement,&J sackmW7 gal water <br /> ❑Bentonite(20%solids) ❑Other <br /> Grout Placement Method ePumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By >-Oriller ❑Pump Contractor ❑ Other <br /> ❑Concrete Pedestal❑Dimensions:Width ft Length ft Thick n ❑Christy Box ❑Stove Pipe <br /> PUMP eSubmersibleElTurbine ❑Other HP PumpS_et 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 /> MINIM HOU,j2 ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-X7.697 <br /> SIGNED ✓! TITLE CXR/`�' DATE �'� Z4 •Z'/ <br /> 1 <br /> V <br /> S <br /> ti <br /> O <br /> Z <br /> DEPARTMENT USE ONLY J t <br /> Application Accepted By Date��d E;�d Area 7 �� Employee&; DA <br /> Grout Inspection By Date^�I I��\ ❑ SPECIAL Well PeITtllt <br /> Pump Inspection By Date ❑ WAIVER Received,.,,y .i\. <br /> Soil Boring Inspection By Date Constructed Well Depth 'i•' (' " ft <br /> COMMENTS Fxis}I*S well rer✓&shs o,groD=,4V Tc, Mi•m)r,ri /On FaD7 SetLzk i'Lm �nirnoF. /rn�s <br /> OT CYILI�$U1P5• <br /> PE SC Received Check# Amount Date Permit/ Invoice# Well ID# <br /> Codes Info Remitted Service Re uest# <br /> 390 05) 1S �[ Z L U <br /> 3(-6 i90 4 9do A l <br /> 9391 )50 -L L-JP03 l v <br /> t <br /> EHD 43-06 6/11/2019 WELL/PUMP PERMIT <br />