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J hq d SOO 1I1 VP <br /> WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS f�EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS r L� CITYIZIP Kc c��- M <br /> �} u n <br /> CROSS STREET �'" APN :22 if 7 nPARCEL SIZE i LAND USE APPLICATION <br /> OWNER NAME ( [ G S.'Y.� i 1�Imlin lL, Pr PHONE 2101 <br /> _+ cin <br /> OWNER ADDRESS � �YY�e CITYISTATEIZIP '7i �t� <br /> CONTRACTOR C i PHONE en E""--7,3 <br /> CONTRACTOR ADDRESS T.o CITYISTATEIZIP ffe, Zj-�, C14 /��2,0 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITYISTATTE/ZIIP <br /> LICENSE a6-57 ❑C-61 ❑D-09 ❑ At-/Other NUMBER � ?b 1 EXPIRATION DATE t 1 <br /> DOMESTIC WELL$AMP, G;❑General Mineral/Coliform Bacteria(4391)❑Dibromochloropropane (4392)❑Arsenic(4393) <br /> INTENDED USE omestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring El Soil Sampling/Characterization <br /> F1 Public WaterSystem <br /> If different from Owner: Water System Name uoniacl Name or Phone Number <br /> TYPE OF WORK E]New Well J2<eplacement Well ❑Well Alteration/Modification F1 Other <br /> ❑Monitoring Well(s) #of wells [-]Soil Boring(s) #of borings #❑ of borings <br /> Geotechnical <br /> ❑Out-Of-Service Well E]Out-Of-Service Well Renewal ❑Gross-Connection Repair <br /> ❑New Pum L]Pump Replacement Lj Pump Repair ❑Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method ud Rotary ❑Air Rotary ❑Auger ❑Cable Tool E]Push Paint ❑ Other <br /> Proposed Well Depth 3 M—j it Excavation in diameter ❑Open Bottom CWavel Pack/Gravel Size in diameter) <br /> ❑Conductor asing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Schad 2 ,Q( ❑Steel <Oic ED Stainless Steel ❑Other <br /> Grout Seal Depth 1470 ft ❑Neat Cement(94 Ib bag/5-10 gaI water) and Cement /10..3 sack mix17 gal water <br /> ❑Bentonite(20°fl solids) ❑Other <br /> Grout Placement Method umped E]Free Fall F]Other ❑Retardant I Accelerator(name) <br /> PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑ Other <br /> ❑Concrete Pedestal Eimensions:Width ft Length ft Thick in [-]ChristyBox ❑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 L _ S. <br /> MINIMU ADV C OTICE REQUIRED FOR INSPECTIONS - PLEASE CALL(209) 95 T7697 <br /> SIGNED TITLE f G /r�� DATE !y//7/1 <br /> Io <br /> 7 <br /> JCIAC ul <br /> 11Cj I 7-' <br /> AL <br /> ja <br /> c <br /> DEPARTMENT USE ONLY <br /> 19 <br /> Application Accepted By3- LA— Date Area f Employee ID# (�17 <br /> Grout Inspection By Date ❑ PECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection,By Date Construc ed Well epth ft <br /> COMJENTS In► a ifZld <br /> zm 0-A <br /> 1�. <br /> PE SC Received Check#/ Am" unt Data Permit/ Invoice# Well ID# <br /> Codes Info B as Remitted Service Request# <br /> EHD 43-06 8101/16 WELL/PUMP PERMIT <br />