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+. WELL/PUMP PERMIT 1 ` <br /> SAN_"�)ACIUIN C-'jUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT ALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS Z" �C CITY/ZIP V' <br /> / 2 `I D <br /> CROSS STREET ;: `C ✓A APN {t� eT L�/1 PARCEL SIZE LAND USE A�PtP�LICATION# p <br /> OWNER NAME PHONE (�U / O r_ cn <br /> a <br /> OWNER ADDRESS � CITY/STATE/ZIP <br /> _ n <br /> e� <br /> ` CONTRACTOR d" � �-� r' PHONE � �y/ � �7x4--- <br /> CONTRACTOR ADDRESS <br /> A^. <br /> � rWs' :28. CITY/STATE/ZIP <br /> l/i L JO <br /> SUBCONTRACTOR I �1I� PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE -57 Ll C-61 LI D-09 I Other NUMBER,?,1#•7 ?,31T- EXPIRATION DATE <br /> DOMESTIC WELL SAMPLING: i General Mineral/Coliform Bacteria (4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization <br /> LI Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK New Well >Aeplacement Well ❑ Well Alteration/Modification ❑ Other <br /> CI Monitoring Well(s) #of wells F1 Soil Boring(s) #of borings CI Geotechnical <br /> Out-Of-Service Well [I Out-Of-Service Well Renewal ❑ Cross-Connection Repair 114M o <br /> New Pum F1 Pump Replacement H Pum Repair ❑ Raise Well Casing �f / <br /> WELL CONSTRUCTION ✓O/ig(�U <br /> Drilling Method or_klud Rotary Cl Air Rotary LIAuger L] Cable Tool LlPush Point I Other H ENVRO Cl� QU <br /> n <br /> Proposed Well Deptht-�I Jft Excavation _ in diameter ❑ Open Bottom 11 Gravel Pack/Gravel Size PAR Teter <br /> ❑ Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing DiameterIn Thickness/Gauge/ASTM Schedj7 !2a ❑ Steel `Plastic 11Stainless Steel F1Other <br /> §c_Grout Seal Depth / > ft ❑ Neat Cement(94 lb bag/5-10 gal water) C Sand Cement —sack mix/7 gal water <br /> LI Bentonite 0%solids) L Other / <br /> Grout Placement Method umped ❑ Free Fall I1 Other FI Retardant/Accelerator(name) <br /> PEDESTAL Installed By Xoriller 11 Pump Contractor I Other <br /> 1 Concrete Pedestal ((Dimensions:Width ft Length T ft Thick in ❑ Christy Box ❑ Stove Pipe <br /> PUMP ,IZubmersible❑ Turbine t l 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 /> MIN 24 HOU ADVANCE NOTICE REQUIRED FOR <br /> ,pINSPECTIONS -PLEASE CALL (209) 953-76/97 <br /> SIGNED Cf�?Y� TITLE ;J/vc�+ DATE <br /> a . <br /> V. <br /> r - <br /> f 4 <br /> D_E ARTMENTU E OANLY <br /> Application Accepted By Date i !/ ,rea Employee ID# <br /> Grout Inspection By VM Date 7 l ( D SPECIAL Well Permit <br /> Pump Inspection By U Date L I WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS 1A1 <br /> PE SC Received Che Amount Permit/ <br /> Code Info ash Remitted Date Service Request# Invoice# Well ID# <br /> tin ! l111 <br /> C� <br /> p 3 l 14 2k) 5 c7L�3 <br /> a <br /> EHD 43-06 8/01/16 WELL/PUMP PERMIT <br />