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i <br />1 • <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 -6232 (209) 468-3420 <br />IvvIY-Rtr'UIVUAtSLt 1"tKMI I <br />JOB ADDRESS <br />CROSS STREET ({/►(/% f <br />OWNER NAME <br />OWNER ADDRESS <br />CONTRACTOR �� r <br />CONTRACTOR ADDRESS <br />SUBCONTRACTOR/CONSULTANT <br />rrz <br />JJ WWW.S ov.or /ehd EXPIRES 1 YEAR FROM DATE ISSUED <br />• j 4:r_ CITY/ZIP Z640 I T_ <br />AP/)N U,,{�� (., c� S 7� PARCEL SIZE IV <br />V LAND USE APPLICATION # <br />�_CIT� �i�t° 1 U I Ne y�'t �s PHONE / L 3— O `y <br />6-78 <br />SUBCONTRACTOR/CONSULTANT ADDRESS <br />LICENSE Ae C-57 ❑ C-61 ❑ D-09 ❑ Other <br />BILLING PARTY: ❑ OWNER IWONTRACTOR <br />CITY/STATE/ZIP <br />�• <br />PHONE 3 3y Y7z r <br />CITY/STATE/ZIP 440 �j♦"/����Q <br />PHONE J 2'7 - <br />CITY/STATE/ZIP <br />7/S, <br />NUMBERS! 77w EXPIRATION DATE Z� <br />❑ SUBCONTRACTOR/CONSULTANT <br />DOMESTIC WELL SAMPLING:X General Mineral/Coliform Bacteria (4391),( Dibromochloropropane (4392) ❑ Arsenic (4393) <br />NTENDED USE 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 rNew Well Replacement Well ❑ 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 <br />Mew Pump ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casino <br /># of borings <br />Drilling Method X Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other // <br />Proposed Well Depth ft Excavation in diameter ❑ Open Bottom Xravel Pack/Gravel Size in diameter <br />❑ Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter 16� in Thickness/Gauge/ASTM Sched L ZO ❑ Steel Plastic ❑ Stainless Steel ❑ Other <br />Grout Seal Depth /ffJ ft ❑ Neat Cement (94 lb bag/5-10 gal water) �W Sand Cement /0,3 sack mix17 gal water <br />❑ Bentonite (20% solids) ❑ Other <br />Grout Placement Method -K Pumped ❑ Free Fall ❑ Other ❑ Retardant / Accelerator (name) <br />PEDESTAL Installed By .5Driller ❑ Pump Contractor ❑ Other <br />❑ Concrete Pedestal ❑Dimensions: Width Z ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe <br />PUMP pO Submersible[] Turbine ❑ Other HP -L- 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 />MINIf PJMJ8 HZUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />E <br />DEPARTMENT USE ONLY <br />i <br />Application Accepted By �� Date I( d Area I Employee ID# <br />Grout Inspection By �rafk:.j( o ckqni%G Date 20A ❑ SPECIAL Well Permit <br />Pump Inspection By Date ❑ WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth ft <br />COMMENTS jAIP.11 !in reW X111 1 Yl USP - <br />T <br />m <br />D <br />0 <br />0 <br />m <br />m <br />PE <br />Codes <br />SC Received <br />Info B <br />Check#/ Amount Date Permit/ Invoice # Well ID# <br />Remitted Service Request # <br />�180 <br />o s l / <br />)sa -7 I <br />H37$ <br />I 8O <br />yao <br />EHD 43-06 6/11/2019 WELL /PUMP PERMIT <br />