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WELL/PUMP PERMIT <br /> SAN JOAtiQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 <br /> NPON-REFUNDABLE PERMIT CALL 209)9�i53-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOBAfJRES." e r l CITY/ZIP �)f1� qSL,3�!' m <br /> +�'�J� D <br /> CROSS STREET {PAS {, �[i J APN -Z Z C/ D PARCEL SIZE AND USE APPLICATION# o <br /> C -1 Q m <br /> OWNER NAME _C D, r1,L�-e ro ( �(rZ\J PHONE `j 1 s�, vi <br /> OWNER ADDRESS l �' CITY/STATE/ZIP <br /> (CONTRACTOR mo'sc I I r l��Wt PHONE- �2-2- <br /> CONTRACTOR ADDRESS 1� CITY/STATE/ZIP o eJ4a; <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP G� <br /> LICENSE �C-57 F1C-61 ElD-09 Ll Other NUMBER �� EXPIRATION DATE L/ -30- <br /> 3(^J <br /> DOMESTIC WELL SAMPLING:CqGeneral Mineral/Coliform Bacteria (4391)❑Dibromochloropropane(4392)❑Arsenic(4393) <br /> INTENDED USE �11omestic/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 XewWell ❑Replacement Well [:]Well Alteration/Modification ❑Other- <br /> ❑Monitoring Well(s) #of wells ❑Soil Boring(s) #of borings ❑Geotechnical #of borings <br /> E]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 /> Drillinj Method Mud Rotary ❑Air Rotary ❑Auger ❑Cpble Tool E]Push Point E] Other <br /> i <br /> Proposed Well Depth ;120 ft Excavation kd in diameter [:]OpenBottom XGravel Pack/Gravel Size in diameter <br /> ❑Conduc Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter� in Thickness/Gauge/ASTM Sched !z--> ❑Steel Plastic ❑Stainless Steel ❑Other <br /> Grout Seal Depth /C7J ft ❑Neat Cement(94 Ib bag/5-10 gal water) [-]Sand Cement sack mix/7 gal water <br /> )ento ite(20%solids) ❑Other <br /> Grout Placement Method umped [-]Free Fall ❑Other [-]Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑Driller PRump 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 /> MINI M 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br /> SIGNED - TITLE/.�-��?'f ri�''�• DATE <br /> 4 <br /> oil <br /> T <br /> E /N <br /> LH T <br /> N <br /> DE ARTMENT USE ONLY {� <br /> J 11A <br /> �1•pplj�,-^atjQn ACC�r,tC� ^` moo. Ai6a--���%{ - _ -iiipluyee ivi+/�t••e t' V <br /> Grout Inspection - Date `i ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection�Byy Date Constructed Weil Depth 4- ft <br /> (:ONiMI_N1Sl/LD1// ' �� J/1'1/sC = 17i �i �� L -,I'- <br /> =l>4eW7 ki�-2'j _—� 7 <br /> PE Sc Received Check#/ Amount Permit/ <br /> Code Info B as Remitted Date Service Request# Invoice# Well ID# <br /> ' 7• .. <br /> qVjq <br /> END 43-06 8/01/16 WELL/PUMP PERMI r <br />