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WELL/PUMP PERMIT <br /> SAN JOAO,*,COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 <br /> NON-REFUNDABLE <br /> PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> by <br /> JOB ADDRESS C •4 6 r CITY/ZIP 410 U-2/ m <br /> CROSS STREET fQ I S APN 163--'6-6- 300 21-60 <br /> AA D <br /> n� r�w_�_.,�,l� f� PARCEL SIZE IK/ LAND USE APPLICATION# <br /> OWNER NAME Cryae j ,`eo /kyL PHONEr` I�//7� ��`� <br /> OWNER ADDRESS ` �r�A rnn,h Dw,� C,I_, CITY/STATE/ZIPC&n&r- • Lf�'( <br /> CONTRACTOR Mase�l; DSI 1`t _ L rtc. PHONE 522- 14?2-5 <br /> CONTRACTOR ADDRESS I \Q A CITY/STATE/ZIP#16dcs-fbl COI ?S.?5 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP Q <br /> LICENSE XC-57 17 C-61 I D-09 I I Other NUMBER EXPIRATION DATE ✓ <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) 1 Dibromochloropropane (4392) Arsenic(4393) <br /> So <br /> INTENDED USE Domestic/Private a Irrigation/Agricultural ❑ Industrial I-I Water Quality Monitoring 11 Soil Sampling/Characterization <br /> IJ Public Water System <br /> If different from Owner. Water System Name Contact Name or Phone Number <br /> TYPE OF WORK XNew Well _i Replacement Well ❑ Well Alteration/Modification ❑ Other <br /> Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings 1 I Geotechnical #of borings <br /> Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> New Pum I Pump Replacement ❑ Pump Repair ❑ Rise Well Casing <br /> WELL CONSTRU TION <br /> Drilling Methodx Mud Rotary I I Air Rotary ❑ Auger i Cable Tool/, [I Push Point 71 Other <br /> ' <br /> Proposed Well Depth 6d ft Excavation � in diamYeetter 17 Open Bottom XGravel Pack/Gravel Size in diameter <br /> I I Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter 1L in Thickness/Gauge/ASTM Sched Steel XPlastic I Stainless Steel I I Other <br /> Grout Seal Depth 2 y ft ❑ Neat Cement(94 Ib bay/5-10 gal water) Sand Cement sack mix/7 gal water <br /> C,j2cz ,,- �< Bentonite(20%solids) ❑ Other <br /> Grout Placement Metho umped 11 Free Fall ❑ Other I Retardant/Accelerator(name) <br /> PEDESTAL Installed By LI Driller I I Pump Contractor Other <br /> Concrete Pedestal I IDimensions:Width ft Length ft Thick in I 1 Christy Box I Stove Pipe <br /> PUMP I I Submersibles] Turbine I I 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 /> MI M 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209)) 95*3�-76/977 <br /> SIGNED TITLE �v'��� DATE / - 7+l0 <br /> r <br /> 1 <br /> J l <br /> r' <br /> JK I <br /> J � <br />` P R T M E N T U,.S E O N L Y <br /> Application Accepted ByDate Area Employee ID# Vt/_ ti 77 <br /> Grout Inspection By Date iiij,2 byLJ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection B Date C cted Well Depth n ft <br /> COMMENTSI 'V I ° <br /> PE SC Received C mount Date Permit/ Invoice# Well ID# t <br /> Codes fo Cash Remitted Service Request# <br /> —a ► <br /> EHD 43-06 8/01116 WELL/PUMP PERMIT <br />