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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 />CALL (ZU91 953-7697 <br />1 YEAR FROM DATE ISSUED <br />JOB ADDRESSliUT <br />CJ {jVy—(ATYIZP <br />r ,c�c., j -Is.SLJ� <br />CROSS STREET <br />y APN <br />�,�I <br />} 1 PARCEL SSIZE f V I �L.AND USE APPLICATION # <br />OWNER NAME <br />PHONE <br />rAr <br />r <br />OWNER ADDRESS <br />` <br />CITY/STATE/ZIP <br />( <br />CONTRACTOR <br />yy�� <br />-1 1 <br />PHONE (to�J C� yj <br />! 1 <br />T�jr <br />(� <br />J <br />1 <br />Air,I <br />L ' <br />�rl� <br />CONTRACTOR ADDRESS <br />✓tel - <br />r ITY/STA P <br />LkI Y <br />7 J <br />SUBCONTRACTOR V J <br />O� I� III fttj <br />PHONE <br />— 7*7 <br />f�� <br />V <br />iW "^[ <br />-S C jL <br />(� <br />SvyJ�v <br />SUBCONTRACTOR ADDRESS <br />1 l J /L.. -- �Sr <br />:J, CITY/STATEM1 <br />'- fL � <br />LICENSE C-57 D C-61 ❑ D-09 ❑ Other <br />NUMBER <br />EXPIRATION DATE4jj <br />W <br />DOMESTIC WELL. SAMPLING: ❑ General Mineral/Coliform Bacteria (4391) D Dibromochloropropane (4392) ❑ Arsenic (4393) <br />NTENDED USE ❑ Domestic/Private D Imgation/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 ❑ New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other <br />❑ Monitoring Well(s) # of wells D Soil Boring(s) # of borings Geotechnical # of borings <br />❑ Out -Of -Service Well ❑ Out -OF Service Well Renewal ❑ Cross -Connection Repair <br />Drilling Method ❑ Mud Rotary ❑ Air Rotary -)(Auger ❑ Cable Tool ❑ Push Point ❑ Other <br />Proposed Well Depth -oft Excavation in diameter ❑ 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 Schad ❑ Steel ❑ Plastic ❑ Stainless Steel ❑ Other <br />Grout Seal Depthft Neat Cement (94 lb bag/5-10 gat water) ❑ Sand Cement sack mix17 gal water <br />D Bentonite (20% solids) ❑ Other <br />Grout Placement Method IkPumped D Free Fall ❑ Other ❑ Retardant /Accelerator (name) <br />PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other <br />❑ Concrete Pedestal ❑Dimensions: Width It Length It Thick in ❑ Christy Box ❑ Stove Pipe <br />PUMP ❑ SubmersibieD 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. UM 4 HOUR ADVANCE NOTICE REQUIRED FOR 1IINSP TI /S�- PLEASE CALL (209) 953-769 <br />SIGNED J TITLE J' U/ ' LY1 al DATE <br />P`A TMENT SE N Y <br />Application Accepted By Date Area Employee ID# <br />Grout Inspection By Date ❑ SPECIAL We11 Permit <br />Pump Inspection ByDate ❑ WAIVER Received <br />Soil Boring Inspection By A-5r7%q 44,L_24 Date . Ild>�t r Constructed Well Depth ft <br />COMMENTS <br />FAService Request# <br />EHD 43-08 8/81/18 WELL/PUMP PERMIT <br />fD/J <br />b <br />A <br />m <br />N <br />N <br />