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e <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 EXPIRES 1 YEAR FROM DATE ISSUED <br /> /� <br /> h �+ L t <br /> JOB ADDRESS 2-In o J �5e q l Qi K &1 I b 1 FL\ CITY/ZIP F-Ir 1K) 1l S 16 1\ q�2_ Q m <br /> m <br /> /' ',p1 IS-7 - <br /> Q ( A <br /> D <br /> CSTREET b 11 y <br /> 3 1A APN 1 -7 r- 1 8 y-0 PARCEL SIZE 153 LAND USE APPLICATION# <br /> CROSS C <br /> r n / p CI- 5313 <br /> � �7 <br /> OWNER NAME C t T M1���� 1]q r *,0 S Z� PHONEZC`I� '( (CI-53 7 y <br /> � p N <br /> OWNER ADDRESS +SG6 r�y.V�-�fyI1V"004 1 ►1 CITY/STATE/ZIP �s(q/f1✓\ �^ 1 5� <br /> CONTRACTOR P)Asti I i S D r 111 1 h QZ",( - PHONELS�' .t Ct 219 ( C <br /> CONTRACTOR ADDRESS 119 At�-5 1''ti� CITY/STATE/ZIP M,4�t s T 6, r o, <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/SST/ATE/ZIP <br /> LICENSE XC-57 ❑C-61 0D-09 ❑Other NUMBER EXPIRATION DATE <br /> hf- <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 Uontact Name or Phone Number <br /> TYPE OF WORK ew Well E]Replacement Well ❑Well Alteration/Modification El Other <br /> ❑Monitoring Well(s) #of wells ❑Soil Boring(s) #of borings #of borings <br /> ❑Geotechnical <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_�IfMud Rotary ❑Air Rotary ❑Auger ❑Cable Tool E]Push Point ❑ Other <br /> Proposed Well Depth 500 ft Excavation 2y t1 in diameter Open Bottom ❑Gravel Pack/Gravel Size in diameter <br /> ❑Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter Jflg. In Thickness/Gauge/ASTM Sched U•Z,SO Steel ❑Plastic ❑Stainless Steel ❑Other <br /> Grout Seal Depth J`P ft ❑Neat Cement(94 lb bag/5-10 gal water) (Sand Cement 1-3 sack mix17 gal water <br /> ❑Bentonite(20%solids) ❑Other <br /> Grout Placement Method Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By [:]Driller ump Contractor ❑ Other <br /> ❑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 /> MI M 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953--7697'1 <br /> SIGNED TITLE DATE <br /> f1 <br /> A <br /> S <br /> r -a <br /> D € ARTMENT U E NLY /�'�� <br /> Application Accepted By Date Area Employee ID#A u� <br /> Grout Inspection By Date / ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection By _ Date Constructed Well Depth Sb0 ft <br /> COMMENTS ob5erol-A ?a6Qdjc -to P(j -•-e <br /> ArlIZV1 t>,Lr�' 6¢9kH o:� s'Q- ,l 5(e -�eeA7 <br /> PE Sc Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info By Cash Remitted Service Request# <br /> 7 _3 AP <br /> EHD 43-06 8/01/16 WELL/PUMP PERMIT <br />