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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 \L:ALL LU9 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS �0 Z f ��n/4 ir.n nc e Vr nri CITY/ZIP 13 7-y i <br />CROSS STREET 3 a/7®� <br />'4' LAND USE APPLICATION #APN 1-)-iS <br />OWNER NAME ` _ �iT/L !r[', PHONE 9r6 - 3 -7y -/U-3 <br />OWNER ADDRESS CF:57r:_ ! OQ CITY/STATE/ZIP ��►�1 G' Z� <br />CONTRACTOR PHONE <br />CONTRACTOR ADDRESS ?t'ty B�nw.. B�„ct CITY/STATE/ZIP wp•� �� m / (Q S'Y6 S / <br />SUBCONTRACTOR &IV�Devi 1. % X. / PHONE ;2r - 3/7 — , 19 CO <br />` <br />SUBCONTRACTOR ADDRESS J_17 F/a, e /�4 / _7 ZA6 G��Innx/ ,.c CITY/STATE/ZIP / %S�s_t Nn, Chi 9c+T <br />LICENSE �-57 ❑ C-61 ❑ D-09 ❑ Other, <br />NUMBER C(12 --/t5 EXPIRATION DATE 03, /" ->�. <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 ❑ New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other <br />❑ Monitoring Well(s) # of wells ❑ Soil Boring(s) # of borings geotechnical _ a of borings <br />❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />LJ New rump u rump meplacemenr a rump Nepalr a Kalse vveii casing <br />WELL CONSTRUCTION <br />Drilling Method ❑ Mud Rotary ❑ Air Rotary huger ❑ Cable Tool ❑ Push Point ❑ Other <br />Proposed Well Depth w So ft Excavation �L in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel Size_ <br />❑ Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑ Steel ❑ Plastic ❑ Stainless Steel ❑ Other <br />in diameter <br />Grout Seal Depth 7,0-5"* ft Neat Cement (94 Ib bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water <br />❑ Bentonite (20% solids) ❑ Other <br />Grout Placement Method ❑ Pumped ❑ Free Fall XOther 7RCA41C ❑ Retardant / Accelerator (name) <br />PEDESTAL Installed By ❑ Driller ❑ Pump 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 />MINIMUM 24 HOUR A,D/V/ANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />SIGNED � --161TITLE I:0,0ye F/U6/"jb0,y_ DATE 2�� 3'// -a <br />DEPARTMENT USE ONLY <br />Application Accepted B Date <br />Grout Inspection By <br />Date <br />Pump Inspection By A� Date <br />Soil Boring Inspection By i�Q6�� Date Z zz ZeS/ <br />COMMENTS <br />Area L �r"-�� Employee ID# <br />C SPECIAL Well Permit <br />C WAIVER Received <br />Constructed Well Depth <br />ft <br />T <br />-a <br />m <br />D <br />v <br />v <br />m <br />m <br />CAti <br />PE <br />CodesInfo <br />SC Received <br />Aec Amount <br />sh Remitted <br />Date Permit/ Invoice # Well ID# <br />i e Request # <br />7 . <br />5�v <br />o , <br />EHD 43-06 8/01/16 WELL /PUMP PERMIT <br />