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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HPZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CA L 209 953-7697 FOR INSPECT19 S EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS ('a-7i1ITY/ZIP �)1�( 'yl ; r 5 C m <br /> - D <br /> CROSS STREET bVVVY ! A ra ZAPN C"�i S PARCEL SIZE V '/'•LAND USE APPLICATION# A <br /> l < 7/'/`x m <br /> OWNER NAME Yl PHONE C) J� -(-7gon <br /> n <br /> f Cf <br /> OWNER ADDRESS I U fc fI� A C,.�f_ C� I� CITY/STATE/ZIP (✓1 4*-o , 6-, --15 2- <br /> CONTRACTOR t,S cis rr <br /> �, PHONE �[-C <br /> ,�/ -- <br /> CONTRACTOR ADDRESS I�r CITY/STATE/ZIP � '� �� o <br /> d <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE C-57 C 61 ❑ D-09 Other NUMBER J(0� EXPIRATION DATE V- J-0-16f <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) 1 Arsenic(4393) <br /> INTENDED USE Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring [I 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 ❑ Replacement Well .." El Well Alteration/Modification ElOther <br /> F] Monitoring Well(s) #of wells Soil Boring(s) #of borings CI Geotechnical #of borings <br /> ❑ Out-Of-Service Well ❑ ut-Of-Service Well Renewal Li Cross-Connection Repair <br /> El New Pum ❑ Pum Replacement ElP Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION <br /> r Drilling Method ><Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable-Tool ❑ Push Point ❑ Other <br /> Proposed Well Depth C2 ft Excavation 7� in diameter 11 Open Bottom 'Gravel Pack/Gravel Size in diameter <br /> ❑ Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter J� in Thickness/Gauge/ASTM Sched 7,56N I Steel CPlastic ❑ Stainless Steel ❑ Other <br /> Grout Seal Depth Cs f ft ❑ Neat Cement(94 lb bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water <br /> Bentonite(20%solids) ❑ Other <br /> Grout Placement Method umped ❑ Free Fall 11 Other 1-1 Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller ❑ Pump Contractor [7 Other <br /> ❑ Concrete Pedestal [IDimensions:Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe <br /> PUMP ❑ Submersible Ll Turbine I-1 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 WI H THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENS LAWS. <br /> MINI UM OUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (20911` 53-7697{ <br /> SIGNED TITLE ®fir 1 l� 'r DATE <br /> P <br /> �h <br /> X <br /> l <br /> e' <br /> z <br /> i w o <br /> zZ <br /> 0 <br /> i 5 <br /> W <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date Area Employee ID# <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection Date ❑ WAIVER Received <br /> Soil Boring Inspection y Date Constructed Well Depth /0 ft <br /> COM NTS c ✓� <br /> f <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B Remitted Service Request# <br /> 352'8 C l Y <br /> 4-3q ov <br /> EHD 43-06 8/01/16 WELL/PUMP PERMI? <br /> P <br />