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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 /> / -4 <br /> P m <br /> JOB ADDRESCITY/ZI <br /> CROSS STREES T APN i r, a D <br /> G J) PARCEL SIZE -I LAND USE APPLICATION# o <br /> m <br /> OWNER NAME �'PHON N <br /> OWNER ADDRESS WX ���� CITY/STATE/ZIP <br /> I <br /> CONTRACTOR PHONEL <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> SUBCONTRACTOR/CONSULTANT PHONE <br /> SUBCONTRACT R/CONSULTANT ADDRESS CI Y/STATE/ZIP <br /> LICENSE C-57 11C-61 ❑ D-09 ❑ Other NUMBER EXPIRATION DATE 7iD/ <br /> BILLING PA TY: ❑OWNER rl CONTRACTOR C SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SA PLING: ❑ General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392)I-i Arsenic(4393) <br /> INTENDED USE Qmestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization <br /> iblic Water System <br /> different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK ❑ New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other <br /> ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings ❑ Geotechnical #of borings <br /> ❑ Out-Of-ServiceW II ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> 11 New Pump Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method ❑ Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other <br /> Proposed Well Depth ft Excavation 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 lb 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 ❑ Pump 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 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 /> M/I��8 DVANCE NOTICE REQUIRED FOR INSPECTIONS -PLEASE CALL(209) 953-76907 <br /> 53-76 7 <br /> SIGNED y TITLE X DATE <br /> 4 <br /> CN /R O <br /> DEPARTMENT USE ONLY /�/� �p'4R14fN <br /> Application Accepted By Date 101-7 ,��w 0 Area l % % Employee ID# r R T <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection By p L:5 t e ��^�,.- , Date l� ( �`�(2✓"Z ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received heck Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B ash Remitted Service Re uest# <br /> L1301 0!y o 47-7 <br /> EHD 43-06 6/11/2019 WELL/PUMP PERMIT <br />