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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 PEEWICALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> m <br /> JOB ADDRESS V"re CITY/ZIPLt vdg" Ca q572-3,6 m <br /> D <br /> CROSS STREET�Y I+CSS APN O PARCEL SIZE Q q.. D USE APPLICATION# <br /> OWNER NAME �eli'hAOT`t .. ii PHONE 3:51-17-20 N <br /> OWNER ADDRESS _M150 <br /> �30 \/n Y% 1 arw�u� bul CITY/STATE/ZIP -Zy;rt o <br /> CONTRACTOR ,' ` 1 I 1 I Iiii PHONE 522 <br /> CONTRACTOR ADDRESS 6 CITY/STATE/ZIP -e -fU 357 <br /> SUBCONTRACTOR PHONE aftVinow <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP /; <br /> LICENSE C-57 ❑ C-61 ❑ D-09 ❑ Other NUMBER EXPIRATION DATE q'3G _l g <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 /> ❑ 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 XMud Rotary ❑ Air Rotary Cl Auger C-244 ijble Tool ❑ Push Point ❑ Other <br /> Proposed Well Depth�_ft Excavation - _ in diameter I I Open Bottom ?(Gravel Pack/Gravel Size in diameter <br /> F`Conducto Casing�—in diameter / Conductor Casing Depth . f ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched�- )(Steel ❑ Plastic ❑ Stainless Ste 1 ❑ Other <br /> Grout Seal Depth ft ❑ Neat Cement(94 Ib bag/5-10 gal water) Sand Cement /00sack mix/7 gal water <br /> ❑ Bento ae(200/( solids) ❑ Other <br /> Grout Placement Method umped ❑ Free Fall ❑ Other I I 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 M 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS -PLEASE CALL (209) 953-7697 <br /> SIGNED s T b r e f le r, DATE V 2—S— <br /> I NW <br /> a. IsO <br /> O MEN <br /> ?TqEh T <br /> DEP RTMENT SE ONLY <br /> Application Accepted By ^ Date Area Employee ID# <br /> Grout Inspection By Date ❑ SPECIAL Well,Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received heck#/ Amount Permit/ <br /> Codes I o ash a fitted Date Service Re uest# Invoice# Well ID# <br /> 3Sg �'1 lb I -15 <br /> -weQ03? <br /> EHD 43-06 8/01/16 WELL/PUMP PERMIT <br />