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f <br /> WELL/PUMP PERMIT <br /> !SAN JOAQUIN COUINTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT /�CALL 20/9)9953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED Ln <br /> 6e:5?-- �/ /�i� L� G7 l(7/ m <br /> JOB ADDRESSCITY/ZIP <br /> } �f 6L qJ D <br /> CROSS STREET ;Er � ( �9M /.�h APN D Ay ��'? PARC L SIZED f Z LAN USE APPLICATION# <br /> kR Tw %� Po P9g3- �Jf <br /> OWNER NAME Z,14- <br /> �J G� vn <br /> Si8OWNER ADDRESS !/ /R V L V STATE/ZIP !/rte <br /> CONTRACTOR /�/,/ J /G,Ciy S� PHONE <br /> c <br /> CONTRACTOR ADDRESS //��IZe2 �'ilJlLGFI.� �� CITY/STATE/ZIP r*A" <br /> SUBCONTRACTOR �/r—��L�lS Ll /�/!� PHONE ^� <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE -57 -61 ❑ D-09 <br /> I Other NU+ma EXPIRATION DATE f <br /> DOMESTIC WELL SAMPLING: i General Mineral/Coliform Bacteria (4391) 1 Dibromochloropropane(4392) i Arsenic(4393) <br /> INTENDED USE Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial I I 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 #of borings <br /> ❑ Out-Of-Service Well ❑ Gut-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> New Pump rl Pump Replacement ❑ Pump Repair l_] Raise Well Casing <br /> WELL CONSTRU TION <br /> Drilling Method XMud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool I1 Push Point El Other P of <br /> Proposed Well Depth_ _ft Excavation in diameter ❑ Open Bottom Gravel Pack/Gravel Size in diameter <br /> CI Conductor Casing in diameter / Conductor Casing Depth ( ft <br /> Well Casing Diameter. in Thickness/Gauge/ASTM Sched GL, ❑ Steel lastic ❑ Stainless Steel ❑ Other <br /> Grout Seal Depth ft CI Neat Cement(94 lb bagl5-10 gal water) ❑ Sand Cement sack mix/7 gal water <br /> )/Bentonite(20%solids) I I Other <br /> Grout Placement Method Vpumped ❑ Free Fall ❑ Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By 1 1 DrillerPump Contractor Cl Other <br /> F1 Concrete ID Concrete Pedestal mansions:Width ft Length_ ft Thickin 11 Christy Box rl Stove Pipe j <br /> PUMP VSubmersibleF1 Turbine I I Other HP Pump Set 1490 ft Standing Water Level <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 /> MI MLVMO ANCE NOTICE REQUIRED FOR INSPECTIONS -PLEASE CALL (209) 953-7697 <br /> SI NED TITLE DATE rzZ <br /> �. <br /> Lull <br /> 1SANj J A U I <br /> =INVIHONMENTAL <br /> a5ARTMENT USE ONLY HEALTH DEPART NT <br /> Application Accepted By Date Area Employee ID# <br /> Grout Inspection By IDate n ❑ SPECIAL Well Permit <br /> Pump Inspection By I Date �?13t)1l'❑ WAIVER Received <br /> Soil Boring spection By Da/t� Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received heck# Amount Permit/ <br /> Codes Info B Cash Remitted Date Service Request# Invoice# Well ID# <br /> �sg�2 11 <br /> op <br /> -7-1 Z) <br /> EHD 43-06 8/01/16 WELL/PUMP PERMIT <br />