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` 'WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> nn953zs� m <br /> JOB ADDRESS �� d� C1 Q� �F'yC. CITY/ZIP �� Q,�Dr m <br /> D <br /> CROSS STREET W.��^ APN Z.c,T—I 14 O ZS PARCEL SIZE�Q0LAND USE APPLICATION# <br /> OWNER NAME c�Q e V_QS,f)tt.r PHONE-701 -8770L N <br /> 2 ^� <br /> OWNERADDRESS ` ` CITY/STATE/ZIP &SCa.1yr\. 4 "15310 310 <br /> CONTRACTOR \ rVQ PHONE 5 45-1105 <br /> CONTRACTOR ADDRESS CCITY/STATE/ZIPMOCIC.5-'O .CA <br /> y <br /> 9 S 3Sb <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY//STATE/ZIP <br /> LICENSE C-57 ❑ C-61 ❑ D-09 I.1 Other NUMBER 2--10 S) 3 EXPIRATION DATE S—3 1 <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane(4392) , Arsenic(4393) <br /> INTENDED USE omestic/Private ❑ Irrigation/Agricultural ❑ 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 Well Replacement Well ❑ Well Alteration/Modification ❑ Other <br /> ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings ❑ Geotechnical #of borings <br /> ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> ❑ New Pump ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method ud Rotary ❑ Air Rotary ❑ Auger [-I Cable Tool LI Push Point ❑ Other <br /> Proposed Well Depth ?)Q0 ft Excavation � in diameter ❑ Open Bottom Gravel Pack/Gravel Size_in diameter <br /> ❑ Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter B_ in Thickn auge/ASTM Sched 5 QqCne 9%�I I Steel lastic ❑ Stainless Steel ElOther <br /> Grout Seal `D'epth eat Cement(94 lb bag/5-10 gal water) [I Sand Cement sack mix/7 gal water <br /> �CBento to(20%solids) Ll Other <br /> Grout Placement Method umped I I Free Fall ❑ Other I I Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller ump 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 /> INIMUM �4 HOU AADVVANCE NOTICE b� UpIR F tQSPECTIONS -PLEASE CALL (20.9) 953-7697 <br /> SIGNED JIXJ — TITLE 1(i ♦ �► DATE —I —2.mz�� <br /> /I U11 <br /> J <br /> IV <br /> RcoU <br /> D p <br /> t <br /> DEPARTMENT USF ONLY G� <br /> Application Accepted By Date Area / Employee ID# f <br /> Grout Inspection By Date II L7 E AL Well Permit <br /> Pump Inspection By Date � WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth <br /> COMMENTS4a L:2 <br /> o v l2 C 0 !o o l a <br /> Lt It <br /> PE SC Received Amount Date Permit/ Invoice# Well ID# <br /> Codes Info Casty Remitted Service Re uest# <br /> 2ru' <br /> 10 11fig <br /> 4: <br /> EHD 43-06 8/01/16 WELL/PUMP PERMIT <br />