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' WELL/PUMP PERMIT <br /> :iAN-JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL(209)95)3-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM)DATE ISSUED <br /> JOB ADDRESS <br /> OJ � j� �r � �/ � CITY/ZIP �C— �7 (!/ m <br /> meq- L� 6/!� p� D <br /> CROSS STREET ;Er � C9A1 /��APN D ey ✓ � PARC L SIZED,2 LAN USE APPLICATION# 0 <br /> OWNER NAME �/� TW �iC PLNE" / F_3— L J 77j� rn <br /> OWNER ADDRESS !/ R L1 (+ (.IT STATE/ZIP <br /> CONTRACTOR //:�// J /�l�i/ PHONE <br /> c <br /> CONTRACTOR ADDRESS Z���L c�l.�' /�'�y CITY/STATE/ZIP _s 1 x-, <br /> SUBCONTRACTOR / SL'�L�1S 1 /U.--�.t�'� PHONE ^� <br /> SUBCONTRACTOR ADDRESS ------- CITY/STATE/ZIP <br /> �//iinn <br /> LICENSE 57 -61 D D-09 I I Other NUMBEK� EXPIRATION DATE F <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) i Dibromochloropropane (4392) ' Arsenic(4393) <br /> INTENDED USE y Domestic/Private [I Irrigation/Agricultural D Industrial a Water Quality Monitoring 13 Soil Sampling/Characterization <br /> El Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK )yNew Well -1 Replacement Well D Well Alteration/Modification D Other <br /> D Monitoring Well(s) #of wells El Soil Boring(s) #of borings a Geotechnical #of borings <br /> L Out-Of-Service Well D Out-Of-Service Well Renewal rI Cross-Connection Repair <br /> New Pum l Pump Replacement D Pump Repair D Raise Well Casing <br /> WELL CONSTRU TION <br /> Drilling Method XMud Rotary D Air Rotary Ll Auger D Cable Tool D Push Point ❑ Other 0 of <br /> Proposed Well Depth�O _ft Excavation / in diameter I I Open Bottom ravel Pack/Gravel Size in diameter <br /> 11 Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter lin Thickness/Gauge/ASTM Sched GL. D Steel lastic D Stainless Steel D Other <br /> Grout Seal Depth �dD ft El Neat Cement(94 lb bag/5-10 gal water) D Sand Cement sack mix/7 gal water <br /> Ybentonite(20%solids) D Other <br /> Grout Placement Method Vpumped Ll Free Fall D Other FI Retardant/Accelerator(name) <br /> PEDESTAL Installed By I! Drillerump Contractor D Other <br /> D Concrete Pedestal D 3 Imensions:Width ft Length ft Thick in 11 Christy Box ❑ Stove Pipe <br /> PUMP _VSubmersibleCi Turbine I i Other HP Pump Set 140 ft Standing Water Level <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 O ANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br /> SI NED TITLE DATE z <br /> W117r <br /> oft <br /> jSA14,jLA2UjjQOjINn <br /> NMENTAL <br /> a5ARTMENT USE ONLY HEALTHDEPARTII <br /> Application Accepted By Date Area Employee ID# <br /> Grout Inspection By ` Date Vim y"I LI SPECIAL Well Permit <br /> Pump Inspection By J Date CI WAIVER Received <br /> Soil Boring spection By Dat Constructed Well Depth ft <br /> COMMENTS * J L� <br /> PE SC Received heck# Amount Date Permit/ Invoice# Well ID# <br /> Codes Info By Cash Remitted Service Request# <br /> 00 , `_ <br /> hl t� <br /> W;;77 <br /> EHD 43-06 9/01/16 WELL/PUMP PERMIT <br />