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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 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS //l�� J U r\/ i f-e-e- " V_j c CITY/ZIP G A t I cel ( 5y J 2- m <br /> CROSS STREET. L/t-e, APN 00� "�36 G { D <br /> N �/� PARCEL SIZE 76. LAND USE APPLICATION# 0 <br /> OWNER NAME patv. C 1� �Nh(L� <br /> PHONE <br /> HONE 613- 5'00 <br /> P <br /> CITYISTATE/ZIPM66tt S fQ C <br /> OWNER ADDRESS lzd <br /> CONTRACTOR PHONE 19 2— J <br /> CONTRACTOR ADDRESS!,( '_� oeFS CITY/STATE/ZIP 0de5t!3 , ("r-1 q 35) <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP 7 <br /> LICENSE VC-57 ❑C-61 ❑D-09 ❑Other NUMBER (06�ZZ EXPIRATION DATE �( J G�, <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: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK )gNew Well ❑Replacement Well ❑Well Alteration/Modification ❑Other <br /> ❑Monitoring Well(s) #of wells ❑Soil Boring(s) #or borings ❑Geotechnical #of borings <br /> F1 Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> ❑New Pump ❑Pump Replacement ❑Pump Repair [-]Raise Well Casio <br /> WELL CONSTRUCTION <br /> Drilling Method'$&ud Rotary ❑Air Rotary ❑Auger ❑Cable Tool E]Push Point ❑ Other <br /> Proposed Well Depth � yo ft Excavation 2—o in diameter ❑Open Bottom AGravel Pack/Gravel Size in diameter <br /> ❑Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter t2, in Thickness/Gauge/ASTM Sched r� Steel ❑Plastic ❑Stainless Steel ❑Other <br /> Grout Seal Depth 5 o ft ❑Neat Cement(94 lb bag/5-10 gal water) Mand Cement f p -3 sack mix17 gal water <br /> ❑Benton ite(20%solids) ❑Other <br /> Grout Placement Method Xurnped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑ Other <br /> E]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 /> MINI 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7`697 <br /> SIGNED p�,�� TITLE D�-.I I/"< DATE 16 �/ /_7 <br /> a` <br /> ' ^V <br /> V <br /> l� <br /> Q <br /> d <br /> TIED ^S <br /> Y <br /> J <br /> i <br /> Ut C U <br /> N <br /> ­qRPNI Aal qR <br /> H tAs <br /> PARTMENT USE ONLY <br /> /0 Area c <br /> Application Accepted By Date Area �� C� Employee ID#� <br /> Grout Inspection By ate 2-1 iZ ❑ SPECIAL Well Permit <br /> Pump Inspection By V Date ❑ WAIVER Receive ` <br /> Soil Boring Inspection By Date Constructed Well Depth (C> ft <br /> COMMENTS A d df + ' <br /> l.1 \ y L <br /> v^ <br /> PE SC ceivedheck#/ Amou t Date Permit/ Invoice# Well ID# <br /> Codes Info B Cas Remitted Service Request# <br /> y3{✓ 2 3q <br /> �� d� <br /> EHD 43-06 8/01/16 , /I 4 = �//�d WELL/PUMP PERMIT <br />