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0\0.VA) <br />WELL/PUMP PERMIT <br /> `-k—f(-\ <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - SfocicroN CA 95205 -6232 (209) 468-3420 <br />NON-REFUND PERMI WWW.S ov.or /ehd EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS I I 14 feb 5 VOr 1 Pt le v i Poi ciTylz,S c A /0--n (a q 5 -3 2,0 <br />CROSS STREET 4 # APN a • 1 Co 4 PARCEL SIZE I 00 LAND USE7PLICATION # <br />OWNER NAME r-t - PlipNE 0 b ,--;7_, 3 <br />OWNER ADDRESS t 0 • 1(3 1 . <br />CITY/STATE/ CCA to I <br />CONTRACTOR ADDRESS d q A Li <br />CONTRACTOR 4 A II 0 4 IA PHO4 <br />U <br />E„, caq --4p/oao p_c____.. ,i <br />CITY IST A LPL'? e i t Ca 5-3 co v <br />SUBCONTRACTOR/CONSULTANT / A PHONE N /-11 <br />SUBCONTRACTOFt/CONSULTANT ADDRESS Ai 1-11 . __yrasTATEizip p iff n <br />LICENSE C-57 y C-61 D-09 OtheV .2- 1 ------NR I 61 (-P 47 0 EXPIRATION DATE f.)13I 17 3 <br />BILLING PARTY: OWNER CONTRACTOR SUBCONTRACTOR/CONSULTANT <br />DOMESTIC WELL SAMPUNG: GerNIMineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic (4393) <br />INTENDED USE Domestic/PrivateN 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 Hopiacement Weil Well Meration/Modification Other <br />Monitoring Well(s) # of wells Soil Boring(s) # of borings Geatechnical # of borings <br />Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair <br />New Pump >Cfump 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 St ve Pipe <br />PUMP X Submersible Turbine Other HP --1-61- Pump Se Set ft Standing Water Level ft <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK 1MLL 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 />MINIMUM 48 HOUR ADVANCE NOTICE REQUIRED FO SPECTIONS - PLEASE CALL (20 53-76 7 <br />SIGNED TITLE <br /> 4! I III DATE gir , <br /> <br />" IIj U. 1031,4":cm--emb., <br />11,E1 wr <br /> <br />11111 111111111 11. INK I • <br />Application Accepted Byle-r7-72-412--- Date glCida ) <br />DEPARTMENT USE ONLY <br />Area (1/46/ Employee ID# 46_ EA/T <br />Grout Inspection By Date SPECIAL Well Permit <br />Pump Inspection By netAgt clat,4 (4 --L% j ZOZA WAIVER Received <br />Soil Boring Inspection By Date________Constructed Well Depth ft <br />COMMENTS \,.....-k.-1.-, %-_,.._1•.S.X.Aiag___‘N)PV-1104,3 --.C-,--- (---PVA-A-1., . Alt <br />PE <br />Codes <br />SC Received I Amount <br />Remitted Date Permit/ <br />Service RegRest f Invoice 4 Well ID• <br />4311 0 so 3/Y(3, -r$71Fo.lo±zi 4()D0L12.193 <br />EHD 43-06 6/11/2019 WELL "PUMP PERMIT