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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.siqov.ora/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> (ter^/}�� / � <br /> JOB ADDRESS J�LJV CITV/ZIP m <br /> CROSS STREET �/ZZ APN l/ PARCEL SIZB-3 LAND USE APPLICATION#d S <br /> OWNER NAME ? PHONE� ' m <br /> m <br /> OWNER ADDRESS W CITY/STATE/ZIP lC/t�r�-,'�' 5 <br /> jj <br /> CONTRACTOR +� PHONE V-A D <br /> CONTRACTOR ADDRESS uY CITY/STATE/ZIP <br /> SUBCONTRACTOR/CONSULTANT PHONE <br /> SUBCONTRACTpR/CONSULTANT ADDRESS ITY/STATE/ZIP <br /> LICENSE rN,C-57 _i C-61 IJ D-09 U Other NUMBE EXPIRATION DATE -v <br /> BILLING PARTY: OWNER CONTRACTOR SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE 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 Li New Well P. Replacement Well ❑ Well Alteration/Modification �i Other <br /> Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings _ Geotechnical #of borings <br /> ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal ri Cross-Connection Repair <br /> ❑ New Pump X Pump Replacement ❑ Pump Repair i Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method h Mud Rotary Air Rotary ❑ Auger ❑ Cable Tool 1.1 Push Point ❑ Other <br /> Proposed Well Depth ft Excavation in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel Size in diameter <br /> r Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched !7 Steel 1 Plastic ( Stainless Steel ❑ Other <br /> Grout Seal Depth ft ❑ Neat Cement(94 Ib bag/5-10 gal water) 1 Sand Cement sack mix/7 gal water <br /> C Bentonite(20%solids) LI Other <br /> Grout Placement Method ❑ Pumped ❑ Free Fall Ll Other (! Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller ❑ Pump Contractor i- Other <br /> ❑ Concrete Pedestal Ll Dimensions:Width ft Length ft Thick in D Christy Box 1-1 Stove Pipe <br /> PUMP V Submersible(I Turbine (1 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 /> WORK COMPENSATION LAWS. <br /> MI IMUM 8 D ANC ICE REQUIRED F R INSP TIONS -PLEASE CALL(209) 953-7697 <br /> SIGNE TITL DATE Or <br /> S - Q <br /> Ij <br /> A O <br /> T f_ <br /> EPARTM ENT USE ONLY <br /> Application Accepted By Date Area Employee ID# <br /> Grout Inspection By DateSPECIAL Well Permit <br /> Pump Inspection By Date I(i:-(Jq WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE Sc Received Ceck Amount Date Permit/ Invoice# Well ID# <br /> Codes Info Bash Remitted Service Request# <br /> 1TIA �1P0 <br /> EHD 43-06 6/11/2019 WELL/PUMP PERMIT <br />