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/_ WELL/PUMP PERMIT P <br /> SAN JbAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 9953-776697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS � � /��—� CITY/ZIP 101 �/�-'/ T m <br /> c 2y G <br /> CROSS STREET APN PARCEL SIZE / aLAND USE APPLICATION <br /> f #` / <br /> •OWNER NAME l/� �/ � PHONE !v,/_ OD/y ( Q rNn <br /> OWNER ADDRESS ///? A,)c OgQ4 �; 3_� (A/' �/ 1rY/STATE/ZIP <br /> CONTRACTOR ^ PHONE <br /> CONTRACTOR ADDRESS Z�Z CITY/STATE/ZIP <br /> SUBCONTRACTOR i-�S I%//��f—L.�/�'9� PHONE <br /> SUBCONTRACTOR ADDRESS �— CITY/STATEE//ZIP <br /> LICENSE e-57 -61 IJ D-09 ❑ Other NUMBER 0 EXPIRATION DATE f <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic(4393) <br /> INTENDED USE tDomestic/Private a Irrigation/Agricultural L Industrial I 1 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 WellF2eplacement Well IJ Well Alteration/Modification F] Other <br /> 116. <br /> toring <br /> ❑ MoniWe/ll(s) #of wells ❑ Soil Boring(s) #of borings ❑ GeotechnicalR�4�� <br /> Ll Out-Of-Service Well I I Out-Of-Service Well Renewal 1J Cross-Connection Repair E® <br /> ew Pump ❑ Pump Replacement I Pump Repair F-1 Raise Well Casing <br /> WELL CONSTRid6TION r j ZU18 <br /> Drilling Methode�'Mud Rotary I! Air Rotary [IAuger n Cable Tool Ll Push Point Li Other �JOAQUI <br /> Proposed Well Depth 20,,%(fE Excavation _ in diameter a Open Bottom /�ravel Pack/Grave TH n 1ameter <br /> ❑ Conductor Casing in diameter / Conductor Casing Depth ft MENT <br /> Well Casing Diameter A in Thickness/Gauge/ASTM Sched rl Steel IJ Plastic Li Stainless Steel ❑ Other <br /> Grout Seai Depth _ft ❑ Neat Cement(94 lb bag/5-90 gal wate/) i_I Sand Cement sack mix/7 gal water <br /> Identonite(20%solids) a Other <br /> Grout Placement Method Oumped ❑ Free Fall ❑ Other I I Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller ACPump Contractor I I Other <br /> i Concrete Pedestal a imensions:Width ft Length ft Thick in f1 Christy Box ❑ Stove Pipe <br /> PUMP ubmersible❑ Turbine I I Other HP Pump Set___&o ft Standing Water Level <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 COMPENS TION LAWS. <br /> MI H DVANCE NOTICE REQUIRED FOR 14SPPEC�TIIONS - PLEASE CALL (209) 95 -7697/' <br /> SIGNED TITLE_ DATE 6/1 :O <br /> 71 r <br /> w <br /> IN <br /> pill L' <br /> PA TMENA/V/� <br /> Y <br /> t01 <br /> A� <br /> Application Accepted By Date Area Employee ID# <br /> Grout Inspection By Date C7 SPECIAL Well Permit <br /> Pump Inspection By Date I I WAIVER Received r(� <br /> 1?p,Til'Soil Boring Inspection By Date nstru ted Well Depth ft <br /> +'VCOMM NTS <br /> vvv <br /> �t PE SC Received heck#/ Amount Permit/ <br /> Code I o as emitted ate Service Request# Invoice# Well ID# <br /> Ccs W a W <br /> v <br /> -5VIV low <br /> EHD 43-06 8/01/16 WELL/PUMP PERMIT <br />