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WELL/PUMP PERMIT P �¢ <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HALELTON AVENUE-STOCKTON CA 95205-(209)468.3420 <br /> NON-REFUNDABLE <br /> cPERMIT <br /> ,, ww CALL(20 953-7691 FOR INSPECTII I �EXPIRES 1 YEAR FROM DATE ISSUED <br /> �✓E,ST [.-i/�� Ay�KL !D CITY/ZIP ��'t'► Ul <br /> Jos ADDRESS _ ig <br /> so� ,, n 7—Ill�3"" yy 7„ D <br /> CROSS STREET sA//�CJ/C F.�7�//.,�C APN 012 7- YQO �✓V PARCEL SIZE, �LAND USE APPLICATION# p <br /> In <br /> OWNER NAME �fLT F�+ 4tU`-' /n PHONE Q vw+ <br /> OWNERADDRESS <br /> )(/J�/ e�f `/r����j�y�- CITY/STATE/ZIP W _[FZ el 2— <br /> CONTRACTOR wAll�-nga*L •rJf�`/�' h7r/ 5 PHONE?') --372 -1y.� <br /> CONTgACTOR ADDRESS. .-S)✓"^�+/�/✓��-'�0"j"-^��/`/r � CITY/STATE21P�SAe- ./��!�+/j"'(�qQ�/ <br /> /RCVR t V'tW �16jn /-'�t-�'��v If- .I�ynL PHONE-���7�-ViOj9-77400 <br /> SUBCONTRACTOR ADDRESS I � V7 '7T+�"- �JCITYISTTATE/7J., (:�,Ac , `, -/✓�' y�.�l�t <br /> LICENSE C-57 C-61 D-09 Other NUMBER•20 r D / EXPIRATION DATE <br /> DOMESTIC WELL SAMPLING: General MineraUColiform Bacteria(439 1) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE Domestic/Private Irrigation/Agricultural C Industrial 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 II Replacement Well Well Alteration/Modification Other <br /> Monitoring Well(s) #of wells Soil Boring(s) #of borings XGeotechnical #of borings <br /> Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair <br /> New Pump Pump Replacement Pump Repair i Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary Air Rotary Puger Cable Tool -.Push Point I Other_ <br /> P�oaed Depth�_ft Excavation k/� in diameter Open Bottom Gravel Pack/Gravel Size in diameter <br /> �L� Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter---In Thickness/Gauge/ASTM Sched C Steel Plastic I i Stainless Steel i Other <br /> Grout Seal Depth L7 it X Neat Cement(94 Ib beg/5-90 gal water) Sand Cement sack mixl7 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 It Thick in Christy Box Stove Pipe <br /> PUMP Submersible Turbine Other HP Pump Set _ft Standing Water Level ft <br /> 1 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 2 OU NCE NOTICE REQUIRED FOR I ECTIONSS--PLLEEASE CALL(209)953-7697 <br /> SIGNED - tl� TITLE A44Ze DATE Ap-6P <br /> IVT <br /> DEVED <br /> 018 <br /> T7 I AA1 LJ <br /> U JW-COUNTY <br /> EN <br /> TAL <br /> IJEkLr T aTMENT <br /> EP TMENT U O L hh <br /> Application Accepted By a Date Area Employee ID#� <br /> Grout Inspection By Date PECIAL Well Permit <br /> Pump Inspection By Date ✓ y WAIVER Received <br /> Soil Boring Inspection By Date i n �)p Constructed Well Depth _ft <br /> COMMENTS <br /> PE Sc Received he Amount ete Permit/ Invoice# Well ID# <br /> Codes Info emitted Service Request# <br /> EHD 43-06 8/01/16 WELL/PUMP PERMIT <br />