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WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1666 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON-KEFUNDABBLE F <br />JOB ADDRESS 3 — <br />GALL (-1U91 953-7b97 FOR INSPECTIONS <br />CITYIZIP <br />FJtYIll 7 YEAR FROM DATE ISSUED <br />CROSS STREET •11 Oj a L �' ' 1�,�A,P{N C>( '17 y 110 17- PARCEL SIZE ND USE APPLICATION # <br />OWNERNAME VLr ^1 'l)/�I t1'Q ,, ^•..JL�y'�, ,�1p-1{-{-�I,yt f ? / �PHONEC�n T:CI -' /72,25 <br />OWNER ADDRESS By r" F • v 11� `-'•'w1 CITY/STATE/LP L_OLI I ,/.�C�, q"r1 Ll (,, .l <br />CONTRACTOR ``� p {'�\1\�/1 I1�' ((�� PHONE .' t/� 3( el — t 00 <br />CONTRACTOR ADDRESS ,1 1-� 7 UCtLk- il'-4 D / . Cn`r/STATEZP GO( &A '17 �j JL-_ <br />SUBCONTRACTOR PHONE <br />SUBCONTRACTOR ADDRESS <br />LICENSE XC -57 n C-61 n D-09 n Other <br />CR7Y/STATEZP <br />NUMBER -L "q (7q EXPIRATION <br />DOMESTIC WELL SAMPLING: n General Mineral/Coliform Bacteria (4391) n Dibromochloropropane (4392) ❑ Arsenic (4393) <br />NTENDED USE n Domestic/Private n Irrigation/Agricultural n Industrial 0 Water Quality Monitoring Soil Sampling/Characterization <br />F1 Public Water System <br />If different from Owner. Water System Name Contact Name or Phone Number <br />TYPE OF WORK n New Well n Replacement Well n Well Alteration/Modification n Other <br />F1 Monitoring Well(s) # of wells )(Soil Boring(.) 12— If of borings n Geotechnical # of borings <br />F] Out -Of -Service Well n Out -Of -Service Well Renewal n Cross -Connection Repair <br />L7 Lam' <br />F1 New Pum n Pump Replacement 1 Pump Repair 1, Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method n Mud Rotary n Air Rotary Auger n Cable Tool n Push Point n Other <br />Proposed Well Depth Ihl —Z5 ft Excavation 6 in diameter n Open Bottom n Gravel Pack/Gravel Size in diameter <br />n Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter 9 in Thickness/Gauge/ASTM Schad 0 Steel n Plastic 0 Stainless Steel n Other <br />Grout Seal Depth 17 — 2-15 ft XNeat Cement (94 Ib bag/5-10 gal water) n Sand Cement sack mW7 gal water <br />F] Bentonite (20% solids) n Other <br />Grout Placement Method n Pumped ;W Free Fall n Other n Retardant / Accelerator (name) <br />PEDESTAL Installed By n Driller n Pump Contractor n Other <br />F1 Concrete Pedestal I IDlmenslons: Width ft Length ft Thick in n Christy Box n Stove Pipe <br />PUMP n Submersible n Turbine n 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 />MINA� M 48 HOUR AD ANCE NOTICE REQUIRED FOR INSPECTIONS - PLEA/SE CALL (209) 953-7697 <br />Sr" -f- <br />SIGNED LZ L. ` TITLE Sr" -f- r �, 1,11,1CJ /"I '{ r i- DATE C'l a <br />EPARTMENT USE ONLY <br />Application Accepted By v-Dete 9 - S'Area Employee ID# <br />Grout Inspection By ate 17 SPECIAL Well Permit / <br />Pump Inspection By V Date F1 WAIVER Received <br />Soil Boring Igspection By , _ _ Date a Constructed Well Depth ft <br />F <br />InN <br />EHD43-06 ,eviaed4114116 WELLIPUMPPERMIT <br />