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I Pli <br /> WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT t CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> Jos ADDRESS 363°1°1 LEF 04yt' CITY/ZIP 'tca''10'k, • �� <br /> m <br /> (-ZROSS STREET t�tD h V-1 ,,�s'�' APN Z4"l -6-76-3V PARCEL SIZE f6.60 LAND USE APPLICATION`#,�) o <br /> T Q� Am�[J y- PHONE r L4q& Cnn <br /> OWNER NAME / <br /> OWNER ADDRESS � ,aS •S � - Ave CITY/STATE/ZIP G440}1 <br /> CONTRACTOR i� �KJyeq``•J�� b`1�AI�J 'C • �/�PHONE ( (� t <br /> CONTRACTOR ADDRESS ` L / 1'-� CITY/STATE/ZIP /1'L Od-ep4 6 �Q !��(� <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP �/_ <br /> LICENSE C-57 [IC-61 Ll D-09 Li Other NUMBER EXPIRATION DATE I Jy ! <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane(4392) ' Arsenic(43A31. <br /> INTENDED USE omestic/Private ❑ Irrigation/Agricultural ❑ Industrial I i Water Quality Monitoring ❑ Soil Sampling/ChaTa—l% Nr <br /> ❑ Public Water System RECD <br /> If different from Owner: Water System Name Contact Name or Phone Number �— <br /> TYPE OF WORK ❑ New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other OCr 0 4 -)Me <br /> #of borings #of borin <br /> ❑ Monitoring Well(s) #of wells Li Soil Boring(s) ❑ Geotechnical <br /> tN <br /> ❑ New PumONM <br /> ervice Wp D ell <br /> Replacement ❑ Pump Repair jlU <br /> Li a Well Renewal D Raise Well Casing Repair <br /> p,,E7COUNTY <br /> WELL CONSTRUCTION <br /> Drilling Method)<Mud Rotary ❑ Air Rotary ❑ Auger El Cable Tool 11 Push Point ❑ Other <br /> Proposed Well Depth_4qO ft Excavation 12- _ in diameter I l Open Bottom Gravel Pack/Gravel Size in diameter <br /> ❑ Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched 2 C)o I I Steel lastic ❑ Stainless Steel ❑ Other <br /> Grout Seal Depth t***450 ft ❑ Neat Cement(94 lb bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water <br /> ,0,1 vento 'te(20%solids) Li Other <br /> Grout Placement Method [_ umped ❑ Free Fall ❑ Other 11 Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other <br /> ❑ Concrete Pedestal []Dimensions:Width ft Length ft Thick in ❑ 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 /> MI UM 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br /> jw <br /> SIGNED TITLE ®�`�tr ' DATE -3- 19 <br /> _ w <br /> _71• S <br /> L"L{ <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date �� Area Employee ID#fi <br /> �C = / <br /> Grout Inspection By Date J F-1PECIAL Well Permit <br /> Pump Inspection By Date Ll WAIVER Received <br /> Soil Boring Inspection By Date Genstructep Well Depth ft <br /> COMMENTS A f lM AAQ 144�4d WWA,�- (A/ 1ysE� v <br /> PE Sc Received 1ChqqW Amount Dae Permit/ Invoice# Well ID# <br /> Cod I fo ash Remitted Service Request# <br /> 19 J�,0,/7 <br /> 0 <br /> EHD43-06 8/01/16 WELL/PUMP PERMIT <br />