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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 />NUN-KEFUNDABLE HERMIT www.Sjgov.org/ehcl LXHIKt=Z5 'I YEAR FROM UATE ISSUED <br />L <br />JOB ADDRESS /C <br />/� �/��' / ITY/ZIP G/i�YN 1 <br />y <br />CROSS STREET APN07i0036? PARCEL SIZE�LAND USE <br />�APPJP�LICATIONN# <br />OWNER NAME /V O !� P�H/ONE / v Z - V 0;0 -S <br />OWNER ADDRESS n j CITY/STATE/ZIP /L. �� 4 <br />CONTRACTOR � �% G� t2o-s'S Or -1 "Z t % PHONE <br />CONTRACTOR ADDRESS / � /U � L�% �,/' CITY/STATE/ZIP <br />SUBCONTRACTOR/CONSULTANT Lri L �?y IL` �N 1� PHONE <br />SUBCONTRACTOR/CONSULTANT ADDRESS <br />LICENSE <;-57 ❑ C-61 ❑ D-09 <br />BILLING PARTY: ❑ OWNER <br />CITY/STATE/ZIP <br />Ll Other NUMBER X-17 7361 EXPIRATION DATE 6-0 <br />❑ CONTRACTOR ❑ SUBCONTRACTOR/CONSULTANT <br />DOMESTIC WELL SAMPLING:X General Mineral/Coliform Bacteria (4391) )(Dibromochloropropane (4392) ❑ Arsenic (4393) <br />INTENDED USE Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization <br />❑ Public Water System ISA' ", <br />If different from Owner: Water System Name Contact Name or Phone Number L-12- �- ��/Q_� <br />TYPE OF WORK New Well ❑ Replacement Well ❑ Well Alteration/Modification <br />❑ Monitoring Well(s) # of wells ❑ Soil Boring(s) <br />❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewa <br />114ew Pump ❑ Pump Replacement ❑ Pump Repair <br />❑ Other <br /># of borings ❑ Geotechnical <br />1 ❑ Cross -Connection Repair <br />❑ Raise Well Casino <br />T <br />m <br />D <br />D <br />D <br />cn <br />m <br />WLL CONSTRUCTION <br />Drill ng Meth d,;ieMud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other „ALT H t <br />DE AR MEN <br />Proposed Well Depth�ft Excavation - in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel Size n diameter <br />❑ Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter in Thickness/Gauge/ASTM Schecl❑ Steel iS Plastic ❑ Stainless Steel ❑ Other <br />Grout Seal Depth./00 ft ❑ Neat Cement (94 lb bag/5-10 gal water) Sand Cement l 1- sack mix/7 gal water <br />❑ Bentonite (20% solids) ❑ Other <br />Grout Placement Method Pumped ❑ Free Fall ❑ Other ❑ Retardant / Accelerator (name) <br />PEDESTAL Installed By 0-Criller ❑ Pump Contractor ❑ Other to <br />❑ Concrete Pedestal ❑Dimensions: Width ft Length ft Thick i6in ❑ Christy Box ❑ Stove Pipe <br />PUMP WirSubmersible❑ 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 />MINGMyM g8HOJJR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 9963-7697 <br />SIGNED /G. �� .: TITLE DATE e'?_ <br />` 7 — '�J� <br />DEPARTMENT <br />%U E ONLY <br />Application Accepted By �: Date g/ y ��°�'� <br />Grout Inspection By Date <br />Pump Inspection By t rtiv.��5+. 1f2c��. �'Lt;t ti Date <br />Soil Boring Inspection By Date <br />COMMENTS <br />Area q� — Employee ID#D_ <br />❑ SPECIAL Well Permit <br />WAIVER Received <br />Constructed WCII Depth <br />ft <br />PE SC <br />Codes Info <br />Received Check#/ Y Amount Date Permit/ Invoice # <br />B Remitted Service Re_quest # <br />Well ID# <br />43$0 OS-) <br />Z )sa N 2U <br />43�6 J190 <br />*yao wL41101 `7 <br />W3Q <br />� ICU t t I r <br />43cia <br />470 I <br />EHD 43-06 6/11/2019 WELL /PUMP PERMIT <br />