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- WELLIPUMP 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.orc�/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESv' V' ` CITY/ZIP ` �G m <br /> S- <br /> CROSS STREET `- S( Pr -- 9C d0 t6 A970a OI LY D <br /> Hon <br /> I R APN (/' PARCEL SIZE � LAD USE <br /> OWNER NAME U <'e PHONE I / J�� <br /> OWNER ADDRESS CITY/STATE <br /> CONTRACTOR , �.�/� `'� + V /,l J Pr6/N.E � <br /> CONTRACTOR ADDRESS VyI'�W I Y/STATE Iy' J U <br /> SUBCONTRACTOR/CONSULTANT PHONE f <br /> SUBCONTRACTOR/CONSULTANT ADDRESS CITY/STATE/ZIP z /\ <br /> LICENSE _ C-57 %C-61 _ D-09 �Other 2 NUMBER�� (T `� �/O EXPIRATION DATE / <br /> BILLING PARTY: OWNER X,CONTRACTOR 1 SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING: ❑General Mineral/Coliform Bacteria (4391) = Dibromochloropropane (4392)0 Arsenic(4393) <br /> INTENDED USE _ Domestic/Private L 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 _ New Well a Replacement Well LI Well Alteration/Modification _ Other <br /> e� 91(a����^yyyy���� #of bor ngs rr s ' <br /> v - Monitoring Well(s) #of wells ❑ Soil Boring(s) - Geotechnic�n1, <br /> I _ Out-Of-Service Well u Out-Of-Service Well Renewal L Cross-Connection Repair 1V En <br /> CA New Pump ❑ Pump Replacement 0 Pump Repair _ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method _ Mud Rotary a Air Rotary Auger _ Cable Tool L Push Point _ Otherholvvj�SeAN Jp <br /> Proposed Well Depth ft Excavation in diameter Open Bottom L Gravel Pkyx-e�� �1�NrUNTYn diameter <br /> _ Conductor Casing in diameter / Conductor Casing Depth ft RTMENr <br /> Well Casing Diameter_ in Thickness/Gauge/ASTM Sched L Steel L Plastic _ Stainless Steel u Other <br /> Grout Seal Depth ft n Neat Cement(94 lb bag/5-10 gal water) Sand Cement sack mW7 gal water <br /> Bentonite(20%solids) i Other <br /> Grout Placement Method - Pumped 5 Free Fall n Other r-, Retardant I Accelerator(name) v ` <br /> PEDESTAL Installed By -_ Driller ump Contractor Other N <br /> _ Concrete Pedestal LiDimensions:Width ft Length ft Thick LO in _ Christy Box U Stove Pipe C <br /> PUMP Submersible- Turbine FI 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 /> CURRE CTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WERS COFTENSATION LAWS. <br /> MU 8 HOUR A OTICE REQUIRI=D FOR INSPECTION✓S - PLEASE CALL (209) 95377697 <br /> SIGNE [TITLE P 1 Y 1 �. DATE C <br /> woz <br /> Li <br /> ll DEPARTMENT USE ONLY (p <br /> Application Accepted By ��yL Date 7 d/ OdO Area �C4 Employee ID# FR <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection By �c B.1 tDate g 1�( 2P2o D WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth _ ft <br /> COMMENTS For nevJ t vie P ol', WPc1aye)ff6S_ <br /> PE SC Received Check Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B as Remitted Service Request# <br /> y38o os I 2 4) 2Q WftqtRgl <br /> EHD 43-06 6/11/2019 WELL/PUMP PERMIT <br />