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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 />I4Vr'I-KtI-UnDAt1Lt rt:Kh"i 1 www.$)gov.org/enD tAF'IKtJ T TEAR FROM LIA/T�E ISSUED <br />Joe ADDRESS �� Ct st E --TC:KGt T cc, ' C o k� I� cITy21P LyL(� l I L- ` t� `7 C -i <br />CROSS STREET 7c'(_... K `ITC nC APN 'L/ m —'; 2 " �` PARCEL SIZE 1 �� / LAND USE APPLICATION X /t <br />OWNER NAME CI S Lt ` I `J C PHONE <br />OWNER ADDRESS \�� `M` `' 1 \ Crry/STATEZP (' J 7(t <br />CONTRACTOR �/ f11 i� 1,] l�f 1�1 TY) L( PHONE <br />11 L �I^ �`✓9 /_'"t / -t <br />CONTRACTOR ADDRESS �. U L� GSC `I � CTTYISTATE/ZIP L'�l, 'i +) C .� �5 c 5:2 <br />TANT <br />SUBCONTRACTORICONSULTANT ADDRESS <br />LICENSE �, C-57 D C-61 D-09 Other <br />BILLING PARTY: D OWNER CONTF <br />CRWSTAATErdb1P_ <br />NUMBER 12LI"13SJ <br />SUSCONTRACTOR/CONSULTANT <br />PHONE <br />EXPIRATION DATE 7 _3) ! �? LX <br />DOMESTIC WELL SAMPLINGA General Mineral/Coliform Bacteria (4391)'ADibromochloropropane (4392) Arsenic (4393) <br />INTENDED USE !' Domestic/Private Irrigation/Agricultural _I 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 New Well Replacement Well Well AlterationlModification '_ . Other <br />Monitoring Well(s) IT of wells ::. Soil Bonng(s) # of bonngs Geotechnical a of bOnn9e <br />Out -Of -Service Well Out -Of -Service Well Renewal Cross -Connection Repair <br />. New Pump !- Pump Replacement _ Pumo Repair Raise Well Casino <br />Drilling Method;I�Mud Rotary I. Air Rotary : Auger i - Cable Tool - Push Point _. Other <br />Proposed Well Depth A, -`> ft Excavation in diameter Open Bottom (Gravel Pack/Gravel Size 1% 4 _ in diameter <br />-Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter � in Thickness/Gauge/ASTM Schad �(, (' [: Steel ,?S Plastic Stainless Steel - Other <br />Grout Seal Depth ) GC It .J Neal Cement (94 lb Dag/5-10 gal water) Sand Cement sack mix/7 gal water <br />G Bentonite (20% solids) T Other <br />Grout Placement Method'A Pumped ❑ Free Fall Other -'. Retardant / Accelerator (name) <br />PEDESTAL Installed By Driller Pump Contractor Other <br />_Concrete Pedestal :'Dimensions. Width 1i It Length R Thick in Christy Box _ Stove Pipe <br />PUMP Submersible.- Turbine Other HP } 117 Pump Set 221 it Standing Water Level _17L it <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. 1 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 />HOUR /`' ANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (2091953-7697 <br />N <br />a <br />m <br />D <br />6 <br />1 <br />�V <br />O DEPARTMENT USE ONLY <br />Application Accepted By Dale Area Employee ID# <br />Grout Inspection By Date r SPECIAL Well Permit <br />Pump Inspection By Data - WAIVER Received <br />Soil Boring Inspection By DateConstructed Well Depth It <br />:OMMENT§&µ/%lm T-l/,17g 7r_�( we // Cc, �.7eT,-rrh - 7rS_ LL)41.^.,,L, eT1 AG.t <br />END43-0 611712019{ I /��/% V�'ELL (PUMP PERMIT <br />L � <br />It <br />Check4V <br />Amount <br />Date <br />PermtV Invoice # Well IDN <br />. Ceeh <br />Remitted <br />S nice Request e <br />/ <br />iso <br />I, <br />(N)L ZS74-1 <br />END43-0 611712019{ I /��/% V�'ELL (PUMP PERMIT <br />L � <br />It <br />