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r <br />WELL/PUMP PERMIT <br />SAN .JOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1866 EAST HAZELTON AVENUE-STOCKTON CA 95205 6232 (209) 468.3420 <br />JOB ADDRESS L <br />CROSS STREET <br />OWNER NAME <br />OWNER ADDRESS <br />A Ctrr/LP Lam. I—%-, 1 L11 7::> C-- L <br />ICEL SIZE 21ML.N. USE APPUCATION k <br />PHONE y� <br />CITY/STATEILP /y <br />ozin ( n cis 35 <br />CONTRACTOR ADDRESS l -V. �.(M �LA�O - CITY/STATE/LPq)ahS,0i lCa t I v' 52 <br />SUSCONTRACTOR/CONSULTANT PHONE <br />SUBCONTRACTOR/CONSULTANT ADDRESS CRY13TAAttE]Zjp <br />LICENSE hC-57 C-67 D-09 Other NUMSER--�.7'/�,L. J E.xPiRATioN DATE <br />BILLING PARTY: OWNER XCONTRACTOR SUBCONTRACTORICONSULTANT <br />DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic (4393) <br />NTENDED USE Domestic/Private Irrigation/Agricultural Industrial Water Ouahty Monitoring Soil Sampling/Characterization <br />Public Water System <br />11 aMerem from Owner Water System Name Contact Name or Phone Number <br />TYPEOF Wom New Well Replacement Well Well Alteration/Modification Other <br />Monitoring Well(s) # of wells Soil Boring(s) a of borings Geotechnical a of borings <br />Out -O( -Service Well Out -Of -Service Well Renewal Cross -Connection Repair <br />New Pump Pump Replacement Pump Repair Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method Mud Rotary Air Rotary Auger Cable Tool Push Pont Other <br />Proposed Well Depth_ft Excavation in diameter Open Bottom Gravel Pack/Gravel Size in diameter <br />Conductor,Casing in diameter I Conductor Casing Denth ft <br />Well Casing Diameter in Thickness/Gauge/ASTM Schad _ heel Plastic Stainless Steel Other <br />Grout Seal Depth It Neat Cement (94 It, bag/. -f0 gal water) Sand Cement sack mix/7 gal water <br />Bertonite (20% solids) Other <br />Grout Placement Method Pumped Free Fall Other Retardant I Accelerator (name) <br />PEDESTAL Installed By Or at Pump Contractor Other n <br />Concrete Pedestal Dim nslone: Width � 11 Length 1f— R Thick T in Christy Box Stove Pipe <br />PUMP TUrD,re Other HP _ Pump Set N Standing Water Level K <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 WIT;WSCALIFORNIA CONT TORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WORKERS AN ttSVE WIL <br />MI U Cf IRED FOR INSPECTIONS -PLEASE CALL (209) 95 -7697 <br />SIGNED TITLE DATE <br />%� DEPARTMENT U/SE'ION7LY <br />7 <br />Application Accepted By ✓" Date —C / , 7 /t7 o Area I Employee ID# P1 <br />Grout Inspection By.,// L _ Date - _ / SPECIAL Well Permit <br />1" <br />Pump Inspection By 4, ,Ea 4:;4 �-'L Date %/AU 7- L WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth ft <br />COMMENTS <br />Permit/ Invoice # 9. <br />L�� • • �:ii/��1�11�JliEir3'� �/'��^i!i!f_IL'�(.:Gh:1� <br />EHD43-05 6111=19 L j q r SSR O51--�> <br />WELL PUMP P-RMIT <br />rA <br />0 <br />D <br />N <br />PAYMENT <br />RECEIVED <br />UN 2 7 2022 <br />AN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />1EALTH DEPARTMEN t <br />