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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 />r4UI4-KtF UNUAIJLLt: YetK(MI IZ <br />rens <br />WWW,/S� <br />CTF'IrK^CJ I TtAK hKUM LJAIt ISSUtU <br />JOB ADDRESS <br />t� <br />1 �`K.J J 1 <br />l\ c <br />V 1 LAN S <br />pVAr <br />� ' I ` CITY/ZIP AC <br />(j ,' V ` � V <br />t Ci 5 ""'Ro <br />CROSS STREET <br />,e�1 <br />X11 0 C)r' �� '1 <br />{� <br />APN O <br />r�l n <br />V �� J `�' � PARCEL SIZE �" C <br />LAND USE APPLICATION # <br />OWNER NAME <br />C n r <br />`th`IV <br />` 1 <br />PHONE <br />OWNER ADDRESS <br />'S 'i'y <br />CITY/STATE/ZIP <br />'/^ L <br />V C1, ` , l /' <br />C <br />A 5 zJ 9 �2J 2 <br />� <br />UCj <br />- -7 79 <br />CONTRACTOR <br />1 f�_ <br />// t <br />PHONEyt <br />.7 1 "' <br />CONTRACTOR ADDRESS <br />P. C 13 <br />dl\ ^1/n <br />C <br />CITY/STATE/LP <br />SUBCONTRACTOR/CONSULTANT <br />SUBCONTRACTOR/CONSULTANT ADDRESS <br />LICENSE )4,C-57 C-61 D-09 <br />BILLING PARTY: OWNER <br />CITY/STATE/ZIP_ <br />Other NUMBER ?`19393 <br />CONTRACTOR SUBCONTRACTOR/CONSULTANT <br />DOMESTIC WELL SAMPLING:x General Mineral/Coliform Bacteria (4391) <br />INTENDED USE omesticfPrlvale Inlgation/Agricultural Industrial <br />Public Water System <br />If different from Owner. Water System Name <br />PHONE <br />EXPIRATION DATE / - 3 1 --J9 <br />Dibromochloropropane (4392) Arsenic (4393) <br />ii Water Quality Monitoring Soil Sampling/Characterization <br />Contact Name or Phone Number <br />TYPE OF WORK XNew Well Replacement Well Well Alteration/Modification Other <br />Monitoring Well(s) # of wells Soil Bonng(s) # of borings Geotechnical <br />Out -Of -Service Well Out -Of -Service Well Renewal Cross -Connection Repair <br /># of borings Sq' r <br />Drilling Method XMud Rotary I Air Rotary Auger Cable Tool Push Point Other <br />Proposed Well Depth AS ft Excavation in diameter Open Bottom ')k Gravel Pack/Gravel Size V-4 _- in diameter <br />Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter 0 in Thickness/Gauge/ASTM Sched Steel Plastic Stainless Steel Other <br />Grout Seal Depth 10C ft Neat Cement (94 Ib bagl5-10 gal water) �K Sand Cement (O j sack mix/7 gal water <br />Bentonite (20% solids) i Other <br />Grout Placement Method Pumped ❑ Free Fall Other IJ Retardant / Accelerator (name) <br />PEDESTAL Installed By 'A Driller ! Pump Contractor Other <br />Concrete Pedestal 'Dimensions: Width 5 ft Length 7 ft Thick in Christy Box ; Stove Pipe <br />PUMP 'ASubmersible: Turbine Other HP �_ Pump Set 5 It 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. 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 />IV <br />V <br />` -e• <br />v <br />1 2021 <br />QUIN C <br />0(J <br />EP'4 �6v . <br />DEPARTMENT US ONLY Q <br />Application Accepted By � ` Date b r>7) t� / Area � � C� Employee ID# <br />Grout Inspection By Date SPECIAL Well Permit <br />Pump InspectiDate 1 WAIVER Received <br />Soil Boring Inspedio By Date Constructed Well Depth ft <br />COMMENTS P1IPf2-1 <br />MM� <br />• .RM <br />IMAWWWANIMM <br />�-W#Zpfffil if", <br />EHD 43-06 6/11/2019 WELL /PUMP PERMIT <br />