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ti <br /> i'0- -; "'IF, ,/'V=: 7.a <br /> ap' CC'3�_ ewr, *o!a) WELL/PUMP PERMIT <br /> E*',N JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 <br /> BION-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS �c N ,a V 1210 / Sys <br /> / CITY/ZIP m <br /> yD <br /> CROSS STREET APN < �1�� D!SZ PARCEL SIZE 3Annom�''- LAND USE APPLICATION# v <br /> � m <br /> OWNER NAME /� PHONE eg5 i�f�/ /'/ N <br /> N <br /> OWNER ADDRESS CITY/STATE/ZIP <br /> CONTRACTOR / � _ — PHONE <br /> CONTRACTOR ADDRESS �/ �L !�L'�LL��f t CITY/STATE/ZIP _J <br /> SUBCONTRACTOR ��s� /h��/�j PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE C-57 0C-61 [I D-09 ❑Other NUMBER '/1��0�1') EXPIRATION DATE / <br /> XA <br /> DOMESTIC WELL SAMPLING:❑General Mineral/Coliform Bacteria (4391)❑Dibromochloropropane(4392)❑Arsenic(4393) <br /> INTENDED USEDomestic/Private ❑Irrigation/Agricultural ❑Industrial [:]Water Quality Monitoring El 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 E]Other <br /> ElMonitoring Well(s) #of wells [-]Soil Boring(s) #of borings #of borings <br /> ❑Geotechnical <br /> E]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))Oflud Rotary El Air Rotary ❑Auger ❑Cable Tool El Push Point ❑ Other <br /> Proposed Well Depth Z ✓ ft Excavation in diameter El Open Bottom ravel Pack/Gravel Size in diameter <br /> F-1 Conductor Casing in diameter / Conductor Casin Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched 6L ❑Steel W_lastic E]Stainless Steel ❑Other <br /> Grout Seal Depth ft ❑Neat Cement(94 lb bag/5-10 gal water) ❑Sand Cement sack mix/7 gal water <br /> ,ventonite(20%solids) ❑Other <br /> Grout Placement Method Napumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) <br /> PEDESTAL <br /> Installed By ❑Driller 'Wump Contractor ❑ Other <br /> E]Concrete Pedestal❑dimensions:Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe <br /> PUMP ubmersible❑Turbine ❑Other HPPump Set ft Standing Water Level ft <br /> I HEREBY CP4TIFY 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 /> MIN U CE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7 997 <br /> SIGNED TITLE � DATE <br /> p <br /> All <br /> 1 -7 rj <br /> EP RTMENAUONLY <br /> Application Accepted By DateAreaEmployee ID#Grout Inspection CUDate SPECIAL Well Permit <br /> Pump Inspection By ! DateLO )� ❑ WAIVER Received <br /> Soil Boring Inspection By Date nstructed Well Depth ft <br /> COMMENTS — '4 <br /> 2- — — +7 <br /> PE Sc Received Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B Cash Remitted Service Request# <br /> �S, 2 5-6-t, N l hA03 VVFO-03602, <br /> 0(_;_0 -ae k 5-13 2 w1? -4 , WrOONT73 <br /> ,V <br /> EHD43-06 8/01/16 7CJ WELL/PUNPPERMIT <br />