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WELL/PUMP PERMIT I -P ' <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />IVUIV-KEFUNDA61-E <br />I.ALL (LUU) <br />U0.5-/bVf FOR INSPECTIONS "I YEAR FROM DATE ISSUED <br />LrF_RMrr <br />JOB ADDRESS 7625— <br />F /-.A �e� Y� <br />jtAl'IKtb <br />CITY/ZIP /YL7,& Q'S�ZO <br />CROSS STREET �j�Ii/� <br />�/,�9 �/,A <br />APN �O / (/� `T / PARCEL SIZE, LAND USE APPLICATION <br /># <br />�f � <br />Imbet <br />/ A y <br />OWNER NAME -•1�/ <br />ii:ri%d� <br />d(/ , <br />OWNERADDRESS <br />] <br />CITY/STATE/ZIP�(/t/ <br />CONTRACTOR �i%i <br />y � <br />S3 - <br />�/«N <br />PHONE <br />CONTRACTOR ADDRESS 110 ' �• <br />�7eh �� <br />CITY/STATE/ZIP 40W. lellf <br />91-L y� <br />SUBCONTRACTOR <br />SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br />LICENSE &,C-57 r] C-61 ❑ D-09 ii Other NUMBER IZ� <br />PHONE 3Z7 —'3/Z& <br />EXPIRATION DATE 10-- / 1�' <br />DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic (4393) <br />INTENDED USE ❑ Domestic/Private ❑ Irrigation/Agricultural -.1 Industrial ❑ 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 Weil [ 1 Replacement Well ❑ Well Alteration/Modification 1-.1 Other <br />❑ Monitoring Well(s) # of wells 1:1 Soil Boring(s) # of borings ❑ Geotechnical # of borings <br />❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />New Pum ❑ Pump Replacement F1 Pump Repair ❑ Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method ❑ Mud Rotary LI Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point I I Other <br />Proposed Well Depth ft Excavation in diameter 1.1 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 [ I Steel ❑ Plastic ❑ Stainless Steel ❑ Other <br />Grout Seal Depth ft ❑ Neat Cement (94 lb bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water <br />❑ Bentonite (20% solids) 11 Other <br />Grout Placement Method ❑ Pumped n Free Fall ❑ Other ❑ Retardant / Accelerator (name) <br />PEDESTAL Installed By 11 Driller ❑ Pump Contractor ❑ Other _ <br />CI Concrete Pedestal 'J Dimensions: Width ft Length ft Thick in U Christy Box ❑ Stove Pipe <br />PUMP (Submersible ❑ Turbine ❑ Other HP S Pump Set__ZAS ft Standing Water Level /D Z 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 MUM 24 HOUR ADVANCE NOTICE REQUIRED FOR (INSPECTIONS -PLEASE CALL (209) 953-7697 <br />SIGNED /W aC TITLE /"/� DATE <br />i V R <br />17 <br />R11 <br />li q c <br />7X, O C <br />A <br />N <br />Q PARTMENT USEOONLY <br />Application Accepted By Date <br />Grout Inspection By Date <br />Pump Inspection By ,�S�A� n 'ti�� Date <br />Soil Boring Inspection By <br />COMMENTS (yL'L._ C t <br />Date <br />Area Employee ID#� <br />D SPECIAL Well Permit <br />Ll WAIVER Received <br />Constructed Well Depth ft <br />rr <br />y <br />0 <br />0 <br />m <br />PE SC Received C <br />Codes Info B C -ash <br />Amount Date ermit/ Invoice # Well ID# <br />Remitted Service Re uest # <br />EHD 43-06 8/01/16 WELL /PUMP PERMIT <br />