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` WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY E:NVIRJNMENTAL 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 /> JOB ADDRESS L% ry_ a�/j (:� CITY/ZIP �— YRS �` �w/!� m <br /> 1 <br /> CROSS STREET /;/j /f'� AP � � � PARCEL SIZE J LAND USE PPLICATIO # A <br /> cn <br /> OWNER NAME ����) �Ga.� ( r,/� VVII" PHONE �? <br /> OWNER ADDRESS 1- (/ CITY/STATE/ZIP - <br /> CONTRACTOR C/' _O.i , PHONE , ] Y / 2-J <br /> 04 <br /> 7 <br /> CONTRACTOR ADDRESS ,,(Y CITY/STATE/ZIP �( y '✓r��l <br /> SUBCONTRACTOR , ' a►�� M PHONE <br /> T� - <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE jC-57 ❑C-61 ❑D-09 ❑Other NUMBERS'-,":2 ? EXPIRATION DATE <br /> DOMESTIC WELL SAMPLING:,WGeneral Mineral/Coliform Bacteria (4391)❑Dibromochloropropane (4392)❑Arsenic(4393) <br /> INTENDED USE omestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring F]Soil Sampling/CharacterizaUQQn <br /> ❑Public Water System ¢JA <br /> If different from Owner Water System Name Contact Name or Phone NumBer <br /> Rac�;:% - r; <br /> TYPE OF WORK `Flew Well F]Replacement Well E]Well Alteration/Modification E]Other <br /> /❑Monitoring Well(s) #of wells E]Soil Boring(s) #of borings F]Geotechnical of ererings <br /> ❑Out-Of-Service Well E]Out-Of-Service Well Renewal ❑Cross-Connection Repair SAIV <br /> ew Pum El Pump Replacement Ll Pump Repair E]Raise Well CasingJOq�(llry <br /> WELL CONSTRUCTION -ACTH 0 ENTAL <br /> Drilling Method*; iWud Rotary E]Air Rotary ❑Auger ❑Cable Tool E]Push Point ❑ Other �pARTMCAII, <br /> Proposed Well Depth�?r J ft Excavation in diameter E]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 'L-70 ❑Steel>k�Plastic ❑Stainless Steel ❑Other <br /> Grout Seal Depth b2, ft L]Neat Cement(94 lb bag/5-10 gal water) Mind Cement-X)),. � sack mix17 gal water <br /> ❑Bentonite(20%solids) F-1Other �` <br /> Grout Placement Methol6<Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By iller ❑Pump Contractor1 ❑ Other <br /> E]Concrete Pedestal Epimensions:Width ft Length ft Thick in ❑Christy Box ]StovePip <br /> PP ❑Submersibl' urbine ❑Other HP Pump Set ft Standing Water Level ft <br /> UM <br /> I HEREBY CERTIFY THAT I HAVE PREFARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. - 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 /> MINIMUM OU ADNCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br /> SIGNED f�� TITLE "f vim DATE <br /> 8 <br /> ' Gv <br /> L S <br /> 1+ 1 _ <br /> Tr <br /> DE ART O. NT � vE O . `Y <br /> Application Accepted By Date 0 , Area qq <br /> Employee ID#�/�N -/ <br /> Grout Inspection By �1 I' "� Date ❑ SPECIAL Well Permit / <br /> Pump Inspection By 11 u bate 1I A WAIVER Received <br /> Soil Boring Inspection By Dat Constructed Well Depth 3� ft <br /> COMMENTS / VFI �-- <br /> - ., I OLf., n w L <br /> WL I <br /> PE SC lReceived hec Amounk Date Perrrr U Invoice# Well ID# <br /> Codes Info B ash Remittedrvice Request# <br /> TTJWN"0- <br /> ( ' 3 �) )177. <br /> EHD 43-06 8/01/16 WELL/PUMP PERMIT <br />