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WELL/PUMP PERMIT <br /> SAN JOA.VJIN 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 /> /► / LA <br /> JOB ADDRESS , 2 ��� �-� �f 1 2 0 CITY/ZIP Iw I CIyX4•ef,:% lC` 1 5 33 m <br /> I 1 D <br /> CROSS STREET �,�r_K }y 1? �Z1 APN 2tl !4 11 O - l! PARCEL SIZErt AND USE APPLICATION# o <br /> X <br /> OWNER NAME V A 1�'-11 j H( 11f PHON /b w <br /> OWNER ADDRESS SUk �. Wilma AV CITY/STATE/ZIP I`1_ ►7 A f/« � JJ <br /> CONTRACTOR / S{I I I �A r lI I vl� te r. PHONE 52-Z-- i Ci L S e <br /> CONTRACTOR ADDRESS i Cp /} �)�Q r7 04, CITY/STATE/ZIP /�' 44f) h n, eS 3 5 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE C-57 ❑C-61 ❑D-09 ❑Other NUMBER "P ,i Z/ EXPIRATION DATE <br /> DOMESTIC WELL SAMPLING:❑General Mineral/Coliform Bacteria (4391)❑Dibromochloropropane (4392)❑Arsenic(4393) <br /> INTENDED USE Domestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring El Soil Sampling/Characterization <br /> ❑Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK XNew Well ❑Replacement Well ❑Well Alteration/Modification ❑Other <br /> ❑Monitoring Well(s) #of wells ❑Soil Boring(s) #of borings ❑Geotechnical #of borings <br /> F1 Out-Of-Service Well E]Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> ❑New Pump ❑Pump Replacement ❑Pump Repair ❑Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method ''Mud Rotary F]Air Rotary ❑Auger ❑Cable Tool E]Push Point ❑ Other <br /> Proposed Well Depth 'mfr' ft Excavation r°L- r� 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 6 in Thickness/Gauge/ASTM Sched 2nr,L ❑Steel 'Plastic E]Stainless Steel ❑Other <br /> Grout Seal Depth , 10 ❑Neat Cement(941b bag/5-10 gal water) ❑Sand Cement sack mix/7 gal water <br /> 'KBentonite(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 INSPECTIONS - PLEASE CALL (209) 953-7697 <br /> SIGNED 5 <br /> C�J� �_ TITLE Dv-*? Ile DATEAV <br /> +f� <br /> i <br /> J iv I <br /> V/ C <br /> /A,- <br /> 0A r. C <br /> v 3 <br /> N ' i <br /> k� RTMENT USE ONLY ,�f� <br /> Application Accepted By Date11�1 Areaaq-1 Employee ID#Ak-�-�Y <br /> Grout Inspection Byftvl�� Date El SPE CIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Borino,��Il!nspefrtiot Rv _ (( / _ Date_ / C"ast.uctc.l...re'. U?"a. <br /> COMMENTS/VT7 ✓Vtm, QUI ZI M. 3 / �[��Q`ld'ji �(� <br /> PE SC Received he Amount Permit/ I <br /> Codes Info B ash Remitted Date Service Request# Invoice# Well ID# <br /> 3`f�e 3 ab <br /> EHD 43-06 8/01/16 WELL/PUMP PERMIT <br />