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V�'+ VELLIPUM ' PERNT <br />SAN JOAQUIN COUNTY. ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 -6232 (209) 468-342.0 <br />NON-REFUNDABLE PERMIT <br />sjgov.org/ehd <br />EXPIRES I YEAR FROM DATE ISSUED <br />JOB ADDRESS U <br />CITY/GIP <br />CROSS STREET <br />APN ` PARCEL SIZE LAND USE APPLICATION <br />OWNERNAME P <br />PHONE o <br />_ <br />-� <br />OWPIER ADDRESS <br />CITY/STATE/GIP 'j/ /IL { G <br />� <br />CONTRACTOR !/l <br />/ <br />G�' <br />PHONE <br />CONTRACTOR ADDRESS <br />CITY/STATE/ZIP l T <br />SU13CONTRACTORICONSULTANT <br />PHONE <br />SUBCONTRACTOR/CONSULTANT ADDRESS <br />CITY/STATE/ZIP <br />LICENSE ❑ C-57 ❑ C-61 ❑ D-09 ibther C NUMBER <br />EXPIRATION DATE �Z <br />BILLING PARTY: ❑ OWNER <br />❑ CONTRACTOR ❑ SUBCONTRACTOR/CONSULTANT <br />DOMESTIC WELL SAMPLING: ❑ General Mineral/Coliform Bacteria (4391) ❑ Dibromochloropropane (4392) ❑ Arsenic (4393) <br />INTENDED USE omestic/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 Jew Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other <br />❑ Monitoring Well(s) # of wells ❑ Soil Boring(s) # of borings ❑ Geotechnical # of borings <br />❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />&ieW Pump ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casino <br />WELL CONSTRUCTION <br />Drilling Method ❑ Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other <br />Proposed Well Depth ft Excavation in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel Size <br />❑ Conductor Casing in diameter / Conductor Casing Depth ft <br />in diameter <br />Well Casing Diameter In Thickness/Gauge/ASTM Sched ❑ Steel ❑ Plastic ❑ Stainless Steel ❑ Other <br />Grout Seal Depth ft ❑ Neat Cement (94 Ib bag/5-90 gal water) ❑ Sand Cement 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 ❑ Driller ❑ Pump Contractor, ❑ Other <br />❑ Concrete Pedestal ❑Dimensions: Width ' ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe <br />PUMP Submersible❑ Turbine ❑ Other HP_�" •� _ Pump Set= ft Standing Water Level ft <br />I HEREBY CERTIFY THAT 1 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 1 AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATION LAWS. <br />T <br />M <br />D <br />0 <br />0 <br />X <br />M <br />Cn <br />Cn <br />I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I <br />D E P A R MENT US O LY <br />f � <br />Application Accepted By Date Z 2Z ZOZ 1 Area _4Employee ID# <br />Grout Inspection By Date ❑ SPECIAL Well Permit <br />Pump Inspection By Date l Z. 2Z- ❑ WAIVER Received <br />Soil Boring In ection By Date Con ructed Well Depth ft <br />COMMENTS _p_ [A% O0 �a I% 1 -Fob ZkLLP_R I�ryo.T <br />PE SC <br />CodesInfo <br />Received <br />Check#/ Amount Date Permit/ Invoice # Well ID# <br />Cash Remit ervice Request # <br />r i c- 2 22 <br />EHD 43-06 6/11/2019 WELL /PUMP PERMIT <br />