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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.sjgov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> 1 In <br /> JOB 1� n7FSS Q Ud CrrY/ZIP S r IU^ `I S Z 4 <br /> /t m <br /> CROSS STREET �l( ICM NAVE y ArPN Q 0c�- 1 tJ O?L- PARCEL SIZE LAND USE APPLICATION# A <br /> OWNER NAME PHONE q l y <br /> OWNER ADDRESS Sal'l Ped" <br /> co CITY/STATE/ZIP n,4 r C-4- <br /> ✓1 <br /> CONTRACTOR /' 4�v1f 0-- (�f ,n l I e`f CO 1 I PHONE 1ZG I J 36- I -L}3 �61 <br /> CONTRACTOR ADDRESS I Q v �Y10l t t f t A l ^/W//�� CITY/STATE/ZIP Lo CZ 5 L J r) <br /> SUBCONTRACTOR/CONSULTANT /V( ( PHONE N//4 <br /> r <br /> SUBCONTRACTOR/CONSULTANT ADDRESS �'1 CITY/STATE/ZIP 1111 <br /> LICENSE /�C-57 C-61 D-09 Other NUMBER V q Qa q EXPIRATION DATEy3 j/7'6 Z I <br /> BILLING PARTY: OWNER ONTRACTOR SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING: I General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392)I Arsenic(4393) <br /> INTENDED USE 1 Domestic/Private Irrigation/Agricultural 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 a New Well Replacement Well Well Alteration/Modification Other <br /> ❑ Monitoring Well(s) #of wells Soil Boring(s) #of borings ,C Geotechnical #of borings <br /> ❑ Out-Of-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 X Auger ❑ Cable Tool Push Point Other <br /> Proposed Well Depth ft Excavation —ll— in diameter Open Bottom Gravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched Steel Plastic Stainless Steel Other <br /> Grout Seal Depth ft Neat Cement(94/b bag/5-10 gal water) Sand Cement sack mix/7 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method Pumped free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller IPump Contractor Other <br /> Concrete Pedestal Dimensions:Width ft Length ft Thick in Christy Box Stove Pipe <br /> PUMP Submersible Turbine Other HP Pump Set ft Standing Water Level ft <br /> I HEREBY CERTIFY THAT 1 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 /> 7>U <br /> 48 HOU ADVANCE NOTICE REQUIRED FOR INSPECTIONS -PLEASE CALL (209) 953-7697 <br /> S , C <br /> SIGNED TITLE /Cr1'ar ✓ �Y 1 iP e Pv\DATE <br /> Z74,14 A <br /> � h N <br /> ~DEPARTMENT U E ONLY <br /> / <br /> Application Accepted By __� Date GS 7 Area s Employee ID# � y <br /> Grout Inspection By Date ❑ PECIAL Well Permit <br /> Pump Inspection By Date F1 WAIVER Received <br /> Soil Boring Inspection By ate l Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received hec Amount Date PermlU Invoice# Well ID# <br /> Codes Info B Cash Remitted Service Request# <br /> OQ Q- L4' <br /> EHD 43-06 6/11/2019 WELL/PUMP PERMIT <br />