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" WELL/PUMP PERMIT f /. <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT CALL (209) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS <br />l 10 OLS <br />14 2& k) L! <br />LCI CITY/ZIP ToO!°) e.4 <br />CROSS STREET _rN <br />�z/ <br />C <br />APN�,) <br />�/ PARCEL SIZE( AND USE APPLICATION # <br />1 OWNER NAME <br />A �I <br />N �` �lI l rG�S <br />PHONE 2�/%—���j — �� 7 <br />OWNER ADDRESS <br />Aa. /ons <br />/� <br />CITY/STATE/ZIP�/1l� 5 '� -3&& <br />CONTRACTOR <br />1, 1�l uI✓IZ4 /✓%� <br />X145 <br />PHONE �� Z - 27 s - <br />CONTRACTOR ADDRESS <br />CONTRACTOR <br />�LG� <br />U i L�.�'J/ �i <br />{"' <br />/`C// <br />/ze-( CITY/STATE/ZIP L�/��1 7Lt ,� �� e;75'_ 7 J <br />SUBCONTRACTOR <br />PHONE <br />SUBCONTRACTOR ADDRESS <br />LICENSE )CC -57 1 C-61 ❑ D-09 EI Other <br />CITY/ST7ATTE/ZIP, <br />NUMBER i /l! 7 <br />EXPIRATION DATE 7/ <br />DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic (4393) <br />INTENDED USE ❑ Domestic/Private C Irrigation/Agricultural I] 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 LI Well Alteration/Modification ❑ Other <br />❑ Monitoring Well(s) # of wells ❑ Soil Boring(s) # of borings ❑ Geotechnical # of borings <br />❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />IY'New Pump ❑ Pump Replacement ❑ Pump Repair 11 Raise Well Casing <br />Drilling Method ❑ Mud Rotary ❑ Air Rotary ❑ Auger i I Cable Tool 11 Push Point ❑ Other <br />Proposed Well Depth ft Excavation in diameter I_I Open Bottom Li Gravel Pack/Gravel Size in diameter <br />❑ Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Sched I_I Steel ❑ Plastic Li 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 />❑ Bentonite (20% solids) ❑ Other <br />Grout Placement Method I I Pumped ❑ Free Fall II Other ❑ Retardant / Accelerator (name) <br />PEDESTAL Installed By CI Driller ❑ Pump Contractor ❑ Other <br />❑ Concrete Pedestal ❑Dimensions: Width ft Length ft Thick in ❑ Christy Box C] Stove Pipe <br />PUMP Submersible❑ Turbine 11 Other HP 7-5 Pump Set&_ft Standing Water LevelC> 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 />MINIM' OUI _DVANC ICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 /Q <br />SIGNED � j TITLE __ - J;CI�I� 7 DATE <br />DE IARTMENT SE ONLY <br />AO -4 Application Accepted By Date <br />Grout Inspection By Date <br />Pump Inspection By o Date <br />Soil Boring Inspection By' <br />Date <br />COMMENTS W u I/ � 1-, '� 00 , girl <br />Area Cda q Employee ID#A�&/ <br />❑ SPECIAL Well Permit <br />❑ WAIVER Received <br />Constructed Well <br />PE SC Received Amount Date Permit/ Invoice # Well ID# <br />Codes Info By Cash Remitted Service Request # <br />I'mo5Alltj <br />ft <br />EHD 43-06 8/01/16 WELL /PUMP PERMIT <br />