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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 12091953-7697 FOR INRPFCTIONR FXPIRFR 1 YFAR FROM nATF IRRIIFn <br />JOB ADDRESS Al. &Oid <br />p �{� CITY/ZIP ML(mfecA �S ✓% <br />CROSS STREET 44APN '�a D3i ^ 3S PARCEL SIZE -4f _ff'ZILAND USE APPLICATION # <br />OWNER NAME Cn4 Pn" 1 , r OS PHONE <br />OWNER ADDRESS 1 &f g l 1�� 0 r1Y ei 87jr767K7 CITY/STATE/ZIP O'll L gmy <br />CONTRACTOR ee r # P VlI -- el PHONE <br />CONTRACTOR ADDRESS 53 CITY/STATE/ZIP Fy-es C1 C� CI.1J7o1aZ <br />SUBCONTRACTOR PHONE <br />SUBCONTRACTOR ADDRESS rCITY/STATE/ZIP <br />LICENSE 5?2_57 ❑C-61 F] D-09 El Other NUMBER EXPIRATION DATE <br />DOMESTIC WELL SAMPLING: ❑General Mineral/Coliform Bacteria (4391) ❑Dibromochloropropane (4392) ❑Arsenic (4393) <br />INTENDED USE ❑ Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization <br />❑ Public Water System <br />If different from Owner:a er ys em ame contact Name or Phone Number <br />TYPE OF WORK ❑ New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other <br />El Monitoring Well(s) # of wells Soil Boring # of borings s) � [Geotechnical y # of borings <br />❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />❑ New Pump ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method E] Mud Rotary [-]Air Rotary Auger ❑Cable Tool E] Push Point ❑ OtherWill! <br />�i <br />Proposed Well Depth 0 -a.- ft Excavation � in diameter [:]Open Bottom ❑Gravel Pack/Gravel Size€�'" �C <br />F1 Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter inThickness/Gauge/ASTMS hed _ ❑Steel ❑Plastic ❑Stainless Steel ❑Other <br />Grout Seal Depth ft WNeat Cement (94 lb bag/5-10 gal water) []Sand Cement sack mixl7 gal " <br />❑Bentonite (20% solids) ❑Other JOAQUIN 01 Ij7 <br />Grout Placement Method []Pumped ❑ Free Fail KOther Tr -?,,n, ❑ Retardant / Accelerator (name) HE=ENTAL 11 <br />PEDESTAL Installed By []Driller ❑ Pump Contractor ❑ Other 1 <br />E] Concrete Pedestal Epimensions: Width ft Length ft Thick in ❑Christy Box []StovePipe <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 />MI MUM 24/,HOANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />SIGNED� TITLE 6fo t'e Zx/ bmt di abK DATE <br />DEPARTMENT USE ONLY <br />Application Accepted By 7 r "�" v v ` _yw�' Date <br />Grout Inspection By Date <br />Pump Inspection By Date <br />Soil Boring Inspection By 1P�txl Date <br />COMMENTS 1I5A $ G6✓�arf'br ran(dd uo tn9 pu+im i IAru1 <br />Ot hoks ►t ria or�K aJQr ray, bae bA l <br />Area 3 n'1G nit . Employee]D# A 'k, <br />❑ SPECIAL Well Permit <br />❑ WAIVER Received <br />/9— Constructed Well Depth <br />ft <br />T <br />1 <br />m <br />D <br />d <br />m <br />m <br />Y <br />PE <br />Codes <br />Sc Received he <br />Info By,, ash <br />Amount <br />Remitted <br />Date Permit/ Invoice # Well ID# <br />Service Request # <br />y57 <br />ISS �Z2 <br />EHD 43-06 6/01/16 WELL /PUMP PERMIT <br />