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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 />IVVIv-KEFUNUABL`E (PERMIT WINW.S ttD <br />ay.or sena ANIKJ 7 YEAR FROM ATE ISSUED <br />JOB ADDRESS i I i g S,;� ,}/� t �'M c 4C�i -AJC if /I 1'l Ctrr/ZJ P LC%G K C <br />CROSS STREET 1rL�1f T�e td Cl l ✓ APN (%-j/��OU-36 PARCELSIZE Lr �I.AM)Un APPL1CA7loN• 7175 <br />7 C <br />OWNER NAME 14'(� CLNS-e y SYi i do r' SO/At 770 / 1 7✓ <br />OWNER ADDRESS --C7 jC{1 rN it + CITY/STATE01a J O M t r, / [� p <br />CONTRACTOR �lU�[I�1�al�, 1 /d1 ^C'1 , ` I r-1 Lf p...ye 9 3100,9 - ? -7 7 1 <br />CONTRACTOR ADDRESS t �lJ + ""1 [� Crry/STATErbp <br />SUBCONTRACTOR/CONSULTANT <br />SUBCONTRACTOR/CONSULTANT ADDRESS <br />LICENSE ,C-57 C-61 D-09 <br />BILLING PARTY: OWNER <br />CITY/STATE/ZIP_ <br />❑ Other NUMBER -;'`I 93 %,� <br />-CONTRACTOR SUBCONTRACTOR/CONSULTANT <br />PHONE <br />EXPIRATION DATE <br />DoMEsnc WELL SAMPLING: General Mineral/Coliform Bacteria (4391) J Dibromochloropropane (4392)' Arsenic (4393) <br />INTENDED USE KDomesticlPrivate Imgation/Agncultural Industrial - Water Quality Monitoring L. Soil Sampling/Charactenzation <br />Li Public Water System <br />It different from Owner. VAL., System Name Contact Name or Phone Number <br />TYPE OF WORK rX New Well Replacement Well Well Alteration/Modification Other <br />Monitoring Well(s)# of wells -; Soil Bonng(s) a of bodnes -. Geotechnical or bonne: <br />Out -Of -Service Well ._] Oul-Of-Service Well Renewal C'. Cross -Connection Repair <br />Drilling Method XMud Rotary -i Air Rotary ; Auger Cable Tool ^ Push Point Other <br />c <br />Proposed Well Depth jC 1) It Excavation in diameter Open Bottom )(43ravel Pack/Gravel Size 1 / -I in diameter <br />I. Conductor Casing in diameter / Conductor Casing Depth it <br />Well Casing Diameter in Thickness/Gauga/ASTM Schad J Steel APtastic i-. Stainless Steel -, Other <br />Grout Seal Depth -i'— ft F Neat Cement (94 111 bag/5-10 gal water) )2( Sand Cement `�� . '� sack mixn gal water <br />Bentonite (20% solids) Other <br />Grout Placement Method )i Pumped -1 Free Fall ❑ Other 3 Retardant I Accelerator (name) <br />PEDESTAL Instaged By F Pump Contractor I Other <br />Concrete Pedestal Dimensions: Width fl Length It Thick In -. Christy Box - Stove Pipe <br />PUMP Submersible'- Turbine Other HP S Pump Set 'i jit Standing Water Level <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 15 <br />CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATION LAWS <br />MINIMUM 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />SIGNED T's'r'%' ! `*� N TITLE \J C }' I L : c1 ., DATE <br />A <br />Application Accepted By <br />Grout inspection By <br />Pump Inspection By <br />Soil Boring Inspection By <br />COMMENTS <br />SC I Received I Check#/ I Amount <br />TMENT U E NLY <br />.—Date 7 W Z/ <br />Date <br />Date <br />Date <br />6/11/1019 <br />�W--9�123 �zL[7 <br />F yM�N r <br />CES vj1) <br />FR 0� 1021 <br />v R�NM�C0UNTY <br />�FPARTMFNT <br />Area -`�L Employee ID#� , <br />I_I SPECIAL Well Permit <br />WAIVER Received <br />Constructed Well Depth ft <br />Pertnw Invoice # Well ID# <br />Service Re uset# <br />(C L� <br />It I/ <br />Z <br />WELL /PUMP PERMIT <br />