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` WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 85205 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS j l ,(�'.y�j -G� CITY/ZIP %114da / ✓S(c�� m <br /> II �� D <br /> CROSS STREET ��r�T U� APN 2-0 i <br /> � " -A) LI PARCEL SIZE C� � LAND USE APPLICATION# A <br /> OWNER NAME 0�'��L/1 !<k" I<1 jV1,Cy p X31 c t PHONE <br /> ' s7LOWNER ADDRESS CITY/STATE/ZIP 15f,44 ? _0 <br /> f�4CONTRACTOR <br /> j�/PHONE 14 <br /> CONTRACTOR ADDRESS I� � 1`�� CITY/STATE/ZIP 6LIYVJ o <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACZC5 <br /> DRESS JCITY/STATE/ZIP <br /> LICENSE ❑C-61 ❑D-09 ❑Other NUMBER (G"F�r*(�' Z4 EXPIRATION DATE <br /> DOMESTIC WELL SA LING:❑General Mineral/Coliform Bacteria (4391)❑Dibromochloropropane (4392)❑Arsenic(4393) <br /> INTENDED USE Domestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization <br /> ❑Publ c Water System <br /> If trent Brent from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK ew Well ❑Replacement Well ❑Well Alteration/Modification ❑Other <br /> [:]Monitoring Well(s) #of wells ❑Soil Boring(s) #of borings ❑Geotechnical #of borings <br /> F-1Out-Of-ServiceWell E]Out-Of-ServiceWell Renewal ❑Cross-Connection Repair <br /> ❑New 5 um [:]Pump Replacement ❑Pump Repair [:]Raise Well Casing <br /> WELL CONSTRUCT21u/d <br /> Drilling Method Rotary El Air Rotary ❑Auger ❑Cable Tool E]Push Point ❑ Other <br /> Proposed Well Depth jf-� ft Excavation Z in diameter ❑Open Bottom welavel Pack/Gravel Size in diameter <br /> ❑Conductft <br /> Conductor Casing in diameter / Conductor Casing Depth <br /> Well Casing Diameter 42 in Thickness/Gauge/ASTM Sched ­0 ' ❑Steel lastic ❑Stainless Steel ❑Other <br /> Grout Seal Depth `k6"i jOt ❑Neat Cement(94 lb bag/5-10 gal water) ❑Sand Cement sack mix/7 gal water <br /> Bent ite(20%solids) ❑Other <br /> Grout Placement Method xPumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑ Other <br /> E]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 ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br /> SIGNED 7 « - TITLE `\ l r DATE <br /> a S N O Q <br /> * IOMNT, <br /> T& <br /> EAl <br /> DEPARTMENVew, <br /> N L Y <br /> Application Accepted By Date Area Employee ID# <br /> Grout Inspection By V41 eg—) ,�-` Date C! G / ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring I <br /> _!..rjspectionnBBy Date Constructed Well Depth 2-5-3 ft <br /> COMMENTS� _�j'�JJ( <br /> PE Sc Received hec / Amount Date Permit/ Invoice# Well ID# <br /> Codes Ifo Byn emitted Service Request# <br /> c 1 1, 0 3 2-- <br /> ETD 43-06 8/01/16 WELL/PUMP PERMIT <br />