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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 />NUN-KEFUNDABLE PERMIT <br />L;ALL (-LUV) V53-/bV/ FOR INSPECTIONS <br />tXPIKhb 1 YEAR FROM UATE ISSUED <br />JOB ADDRESS <br />S ` (/_-i"„,y" <br />l <br />/ r{ �( rZ'Iia <br />CITY/ZIP <br />ncie <br />176- <br />+ <br />CROSS STREET 1041, <br />�%� <br />(1'4V <br />� f _I r' V �) <br />t- IV e- A P N �3 J/U Cl/G <br />& I <br />PARCEL SIZE <br />LAND USE APPLICATION # <br />OWNER NAME <br />Yu " <br />-� <br />1✓ <br />O <br />F 14547 <br />OWNER ADDRESS <br />j <br />A' S L'v 161 / I } � Z(! t -C t 5' <br />�CITY/STATE/ZIP <br />r�lV � <br />_a <br />C" � 7)5-3 16, <br />CONTRACTOR iye <br />1' ✓' <br />A "ie� i( 41 �" 1 ZrL <br />7�1.3;e <br />CONTRACTOR ADDRESS <br />/[moi <br />%J <br />' C/oSt%lC d t("L11 <br />CITY/STATE/ZIP <br />/—PHONE <br />SUBCONTRACTOR <br />Sa trU <br />PHONE <br />SUBCONTRACTOR ADDRESS <br />LICENSE W-57 ❑ C-61 ❑ D-09 ❑ Other <br />CITY/STATE/ZIP <br />NUMBER �'/L � EXPIRATION <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 Gontact Name or Phone Number <br />TYPE OF WORK ❑ New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other <br />❑ Monitoring Well(s) # of wells ❑ Soil Boring(s) # of borings Geotechnical # of borings <br />F-1 Out -Of -Service Well ❑Out -Of -Service Well Renewal ❑Cross -Connection Repair <br />Ivew rum <br />fraise vveu uas <br />Drilling Method �*vud Rotary ❑Air Rotary Wuger El Cable Tool E] Push Point ❑ Other <br />Proposed Well [Depth 15 - S�/ ft Excavation (I-' in diameter El Open Bottom []Gravel Pack/Gravel Size in diameter <br />❑ Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑Steel [-]Plastic []Stainless Steel ❑Other <br />Grout Seal Depth ft Neat Cement (94 /b bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water <br />❑ Bentonite (20% solids) [OtherSu_jlhit <i zt<v / Li> �A*— "fit; , el t".rg' <br />Grout Placement Method E]Pumped E]Free Fall ElOther ❑ 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 />MI UM 24 HOUR�ApVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />SIGNED 4�' G.� /��""' TITLE['(�C�`/ryl /'j l�s`/%t /-I (Y�G�U)l�' DATE <br />�4 <br />ESP RTMENT USE ONLY <br />Application Accepted By Date Z <br />Grout Inspection By Date <br />Pump Inspection By I I Date p <br />Soil Boring Inspection By A?� 40Date <br />Fv <br />COMMENTS <br />Area Employee ID#A10 <br />❑ SPECIAL Well Permit <br />❑ WAIVER Received <br />Constructed Well Depth ft <br />PE Sc Received Check#/ Amount Dae Permit/ Invoice # Well ID# <br />Codes Info B Cash Remitted Service Request # <br />o 2, 17 !a <br />EHD 43-06 6/01/16 WELL /PUMP PERMIT <br />T <br />