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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 /> JOB ADDRESS G /V v CITY/LP <br /> / h m <br /> CROSS STREET CJLJ L V APN 0 3PARCEL SIZE � LAND USE APPLICATION# o <br /> M <br /> OWNER NAME f'—� JL Ik �PIICI "11 PHONE <br /> OWNER ADDRESS 3�S3 Pln �C eS CITY/STATE/ZIP ��e�r j U <br /> CONTRACTORS �� PHONE <br /> CONTRACTOR ADDRESS '07� CITY/STATE/ZIP L'e"Ina <br /> / <br /> SUBCONTRACTOR/CONSULTANT !� r .:r 1 PHONE <br /> SUBCONTRACTOR/CONSULTANT ADDRESS CITY//STATE/ZIP <br /> LICENSEC-57 ❑ C-61 ❑ D-09 71 Other NUMBER / 7 ^� EXPIRATION DATE - <br /> BILLING PARTY: I OWNER J CONTRACTOR SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING;k General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) i_. Arsenic(4393) <br /> INTENDED USE omestic/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 ;4ew Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ 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 ❑ Cross-Connection Repair <br /> ew Pump ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Methodo<Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other <br /> Proposed Well Depth 3 ft Excavation /'2- in diameter ❑ Open Bottom ,'Gravel Pack/Gravel Size in diameter <br /> ❑ Conductor Casing in diameter / Conductor Casing Depth ft <br /> u <br /> Well Casing Diameter C in Thickness/Gauge/ASTM Sche _'6D ❑ Steel- X'lastic ❑ Stainless Steel ❑ Other <br /> Grout Seal Depth%t3')� ft ❑ Neat Cement(94 lb bag/5-10 gal water) 'Sand Cement f sack mix17 gal water <br /> ❑ Bentonite(20%solids) ❑ Other <br /> Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By B?triller ❑ Pump Contractor ❑ Other <br /> ❑ Concrete Pedestal []Dimensions:Widthft Length ft Thick in LlChristy Box L) Stove Pipe <br /> PUMP )6ubmersible❑ 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 /> MINIMUM 48 HOU ADVANCE NOTICE REQUIRED FOR(INSPECTIONS-PLEASE CALL (209) 9//5''''3-76977> � <br /> SIGNED �2f.. TITLE t�Ly�- L DATE (a" iti' l <br /> r � <br /> r ' <br /> 41 1 <br /> NI <br /> S' <br /> J 711 <br /> T N <br /> DEPARTMENT USE ONLY gRTMHr <br /> Application Accepted By �— Z Date Area Employee ID# <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received C' <br /> Soil Boring Inspection By Date Constructed Well Depth .7,_5`� ft <br /> COMMENTS /_X/5 1i'A well -jn r'PY2G1Y1 <br /> PE SC Receivedheck#/ Amount Dat Permit/ Invoice# Well ID# <br /> Codes Info B Remitted I ervice F3,equest# <br /> yo Ds) 9 24 11 s <br /> H37$ Igo adcvqi <br /> Wn, � Iso « to <br /> G a <br /> 370 1 1 <br /> EHD 43-06 6/11/2019 WELL/PUMP PERMIT <br />