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WELL/PUMP PERMIT <br /> 'SAN,30AQUIN 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 1YEAR FROM fDATE ISSUED.11 N <br /> JOB ADDRESS CITY/ZIP L A-C n (_�+Ct QS L 3CjM <br /> DL D <br /> CROSS STREET I k APN �Q /��I 0 PARCEL SIZE AND USE APPLICATION# S <br /> OWNER NAMEDe rc, <br /> u V< \,A I V%'Q 1 PHONE y <br /> r 1483- <br /> OWNER ADDRESS i T([��`—�� (�j{7SOnI 1 J / <br /> CITY/STATE/ZIP K-A L I l/t ' *✓f �A <br /> CONTRACTOR M P 1 Cl b e I III\4 L --r—no PHONE 57 2— {7[ 2QSC <br /> CONTRACTOR ADDRESS �l�(�l S A CITY/STATE/ZIP Md-e s to C_� / 535, ' <br /> SUBCONTRACTOR PHONE T <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE XC-57 ❑C-61 ❑D-09 ❑Other NUMBER EXPIRATION DATE <br /> DOMESTIC WELL SAMPLING:❑General Mineral/Coliform Bacteria (4391)❑Dibromochloropropane(4392)❑Arsenic(4393) <br /> INTENDED USE omestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization <br /> ❑Public Water System <br /> if different from Owner: Water System Name Uontact Name or Phone Number <br /> TYPE OF WORK SXNew 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 ❑Out-Of-Service Well Renewal E]Cross-Connection Repair <br /> ❑New Pump ❑Pump Replacement ❑Pump Repair ❑Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method)<Mud Rotary ❑Air Rotary ❑Auger [:]CableTool ❑Push Point ❑ Other <br /> Proposed Well Depth 30p ft Excavation f Zoe in diameter ❑Open Bottom Gravel Pack/Gravel Size in diameter <br /> F-1 Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter 11 in Thickness/Gauge/ASTM Sched ') OCA ❑Steel Plastic E]Stainless Steel ❑Other <br /> Grout Seal Depth 1,6e) ft ❑Neat Cement(94 Ib bag/5-10 gal water) [-]Sand Cement sack mix/7 gal water <br /> Bentonite(20%solids) ❑Other <br /> Grout Placement Method>[Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑ Other <br /> ❑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 IN - PLEASE CALL (209) 953-7697 <br /> SIGNED �—tJN TITLE V rt ot-c . DATE <br /> r <br /> t' <br /> C <br /> C <br /> T r AW <br /> V <br /> - V rave <br /> V SAM <br /> ) I <br /> r E Ic <br /> i}, ,1 T p AL <br /> 4 � . EP RTMENT S ONLY T <br /> 5:t <br /> Application Accepted By1p <br /> Date Area Employee ID# <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection B Date ❑ WAIVER Received <br /> Soil Boring Inspection By Date Construc ed Well Depth ft <br /> COMMENTS <br /> IN j <br /> PE Sc Received Checjji) Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B Cash Remitted Service Request# <br /> XW <br /> L; �y I ig 7710 <br /> EHD 43-06 8/01/16 WELL/PUMP PERMIT <br />