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sk WELL/PUMP PERMIT VIA <br /> SAN,iVAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS yE,,_XPIRES 1 YEAR FR(^O�M DATE ISSUED <br /> 41 <br /> JOB ADDRESS 4 -L o • ` re-�-1�, I--a�n e. CITY/ZIP � l o o� r `7��) L— m <br /> ,1 / D <br /> CROSS STREET E• O T MM r�_l�L�.APN O 85 —300 —I le PARCEL SIZE •6 LAND USE APPLICATION# �j �v� A <br /> ca t� vC \el ¢. Lu PHONE - �O�o SW m <br /> OWNER NAME m <br /> OWNER ADDRESS 4 90 2— E_. \ A rCA`\+ , CITY/STATE/ZIP��wK*o It,C or —1S.2j f_ _ <br /> CONTRACTOR Rr_nh111 5 f-OS, `1 1 1� ��. ��C. ��PHHO��NE 2209 -5 y `5 - ) � S� <br /> CONTRACTOR ADDRESS O CITY/STATE/ZIP�""1 ��, <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE C-57 ❑ C-61 Cl D-09 1i � IV Other NUMBER )3.- EXPIRATION DATE <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE omestic/Private ❑ Irrigation/Agricultural ti Industrial I1 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 WORKNew Well ❑ Replacement Well F] Well Alteration/Modification 1-1 Other <br /> ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings I Geotechnical #of borings <br /> ❑ Out-Of-Service Well ❑ 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 LI-Air Rj Lary ❑ Auger ❑ Cable Tool ❑ Push Point t_1 Other <br /> O <br /> Proposed Well Depth ft f�ft:'ExcavationIL in diameter I I Open Bottom Gravel Pack/Gravel Size i� in diameter <br /> ❑ Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter._G& in Thickness/Gauge/ASTM Sched 5A 11 Steel Plastic ❑ Stainless Steel ❑ Other <br /> Grout Seal Depth���' t ❑ Neat Cement(94 lb bag/5-10 gal water) I,I Sand Cement sack mix/7 gal water <br /> ��/ entonite(20%solids) a Other <br /> Grout Placement Method . Pumped fl Free Fall ❑ Other 11 Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller Pump Contractor CI Other <br /> ❑ Concrete Pedestal ❑Dimensions:Width ft Length ft Thick in 17 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 NPTICE bEQUIR ORI SPECTIONS - PLEASE CALL (209) 953-7697 <br /> SIGNED V `�� . ITLE �L •�+ DATE — 11 —J8 <br /> sm <br /> O <br /> � � O <br /> R <br /> DEARTM1IENT SE LY <br /> 14/,� <br /> Application Accepted By Date > Area 4qEmployee ID# <br /> i <br /> Grout Inspection By /� Date Ati 11 & ❑ SPECIAL Well PerMit <br /> Pump Inspection By Date ❑ WAIVER Received J <br /> Soil Boring Inspection By D to Constructed Well Depth ft <br /> MENTS 1v\ ii fC+r—�r <br /> =, 14 r <br /> PE Sc Received heck Amount Permit/ <br /> Code I o Ey,, ash emitted Date Service Request# Invoice# Well ID# <br /> i� <br /> eor <br /> EHD 43-06 8/01/16 ' p j o'�' ` + l- r �� v WELL/PUMP PERMIT <br />