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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 /> NON-REFUNDABLE PERMIT WWW.S OV.Or /ehd EXPIRES 1 YE R FROM DATE ISSUED <br /> / m <br /> JOB ADDRESS Z e CITY/ZIP ti Cr �m <br /> 1� Dj <br /> CROSS STREET •" ' nx VC/ APN ✓ PARCEL SIZE _,LAND USE APPLICATION# A <br /> m <br /> OWNER NAME PHONE <br /> OWNER ADDRESS Crry/STATE/ZIP G� <br /> CONTRACTOR a� 1 c t: ,(/�, J1 L <br /> W133 `r(�!A <br /> PHO�N�E <br /> CONTRACTOR ADDRESS IV Spe, 0MCITY/STATE/ZIP VOrr �SUBCONTRACTOR/CONSULTANT / yI I C 10 <br /> /t0 <br /> / <br /> SUBCONTRACTORICONSULTANT ADDRESS �4M• CRYISTAATEIZIP c# CILC b <br /> W301LICENSE W C-57 C C-61 D-09 Other NUMBER l EXPIRATION DATE 10 <br /> BILLING PARTY: ❑OWNER CONTRACTOR ] SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING:❑General Mineral/Coliform Bacteria(4391)❑Dibromochloropropane(4392)❑Arsenic(4393) <br /> INTENDED USE 7 Domestic/Private ❑Irrigation/Agricultural C Industrial ❑Water Quality Monitoring V Soil Sampling/Characterization <br /> 7 Public Water System <br /> If different from Owner. Water System Name Contact Name or Phone Number <br /> TYPE OF WORK i New Well I I Replacement Well i Well Alteration/Modification I I Other <br /> -1 Monitoring Well(s) #of wells r Soil Borings) #ofbodngs Geotechnical #of borings <br /> Out-Of-Service Well L Cut-Of-Service Well Renewal u Cross-Connection Repair <br /> 7 New Pum 7 Pump Replacement ❑Pump Repair ❑Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method,/Mud Rotary� ❑Air Rotary 1j Auger El Cable Tool 7 Push Point 7 Other <br /> Proposed Well DepthF^ (( <br /> yit Excavation in diameter C Open Bottom C Gravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth it <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Schad C Steel C Plastic D Stainless Steel ❑Other <br /> Grout Seal Depth ft VNeat Cement(94 Ib bag/5-10 gal water) C Sand Cement sack mix/7 gal water <br /> -1 Bentonite 20%solids) n Other <br /> Grout Placement Method Pumped -1 Free Fall -1 Other -1 Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑Driller C Pump Contractor ❑ Other <br /> D Concrete Pedestal❑Dimenslons:Width ft Length it Thick in ❑Christy Box ❑Stove Pipe <br /> PUMP I Submersible❑Turbine ❑Other HP 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 /> MI IMU 48 H ADVANCE NOTICE REQUIRED FOR <br /> (INSpPI 10 _'C PLEASE CALL(209)9513-797 <br /> SIGNED TITLE ,S r•" L ✓rZt a//CfSpr DATE l G <br /> AZECE d,p o <br /> L 12 2019 <br /> AQUIN COUNTY <br /> RONMENTAL <br /> -. D"EPARTMENT USE O LY dEPARTMEN " <br /> Application Accepted By Date 5 Area mployee ID# <br /> Grout Inspection By Date 4--� SPIECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#/ Amount Date Permitl Invoice# Well ID# <br /> Codes InfoCash Remitted Service Re uest# <br /> V l 'I <br /> EHD43-06 6/11/1019 WELL/PUMP PERMIT <br />