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WELL/PUMP PERMIT <br /> SAN JQAQUM COUNTY ENVIRONMENTAL HEALTH DEPARTMEK r 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 ADDRESSLA <br /> 7 7�i�v v /v� ,//T m <br /> CITY/ZIP ��/�G{ �s <br /> CROSS STREET L nY / f�� / �) D <br /> /` �(�� APN�'[ 1 [�j0� (/ PARCELL SIZE J' LAND USE`APPLICATION#y� p <br /> OWN�NAM� (Q J Y �e l/�� /// PHONE 6�� �U�7� vi <br /> OWNER ADDRESS �►nn�ap CITY/STATE/ZIP <br /> / <br /> CONTRACTOR ( aaf-'-7 �l ',PHHONE7� C��f <br /> CONTRACTOR ADDRESS C/L/CITY/STATE/ZIP Oal J//j(,0 a <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS �C-IIT�Y//STATE/ZIP <br /> LICENSE C-57 ❑C-61 0D-09 E]Other NUMBER377:395 7:3DJ EXPIRATION DATE ��✓ <br /> DOMESTIC WELL SAMPLING:❑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: a er ys em ame 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( ) ❑Geotechnical 5 #of borings #of borings <br /> Out-Of-Service Well E]Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> ew Pump ❑Pump Replacement [:]Pump Repair ❑Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Methodlud Rotary ❑Air Rotary ❑Auger ❑Cable Tool E]Push Point ❑ Other <br /> Proposed Well Depth-75,00 t) ft Excavation IV in diameter ❑Open Bottom Gravel Pack/Gravel Size in diameter <br /> ❑Conduipi Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM SchedZ00 El Steel X11astic E]Stainless Steel ❑Other <br /> Grout Seal Depth !!�2Lft ❑Neat Cement(941b bag/5-10 gal water) Ili Sand Cement�d i� sack mix17 gal water <br /> F1 Benton ite(20%solids) ❑Other /' <br /> Grout Placement Method,<Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By 05riller ❑Pump Contractor ❑ Other 0 K2 <br /> E]Concrete Pedestal Epimensions:Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe <br /> PUMP E ubmersible❑Turbine ❑Other HP 17 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 /> MINIMUM 24HO DVANC NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 9553-7697 <br /> SIGNED TITLE 1��� DATE 6 / 'Z/ <br /> 7 F71 iL <br /> n 1 <br /> l <br /> IN G( LIQ � <br /> E-"VIRON of A <br /> J <br /> Dr PARTMENTUS7 ONLY n <br /> Application Accepted Date Y�/ Z Area �'i Employee ID#�� <br /> Grout Inspection By Date_ ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection By Dae onstructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#/ Amount Permit/ <br /> Codes Info B Cash emitted Date Service Request# Invoice# Well ID# <br /> 3— a- aZ) L 11 z <br /> EHD 43-06 8/01/16 WELL/PUMP PERMIT <br />