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t 06 WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 <br /> s <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS ^ �, CITY/ZIP In fi/ <br /> m <br /> D <br /> CROSS STREET S / A,P_N 02'q" 00 PARCEL SIZE �LANDSE APPLICATION# A <br /> OWNER NAME � � [�/�J2`/�/LY��/�tlN PHONE yap- U) <br /> OWNER ADDRESS /J,}�/, �h ` CITY/STATE/ZIP <br /> CONTRACTOR /��}- /JV/�pa^�-� / / /f,�g PHONNE 3 - �a7 <br /> CONTRACTOR ADDRESS I� ?ruI CITY/STATE/ZIP t/-- S/ � <br /> SUBCONTRACTOR &t �/7 C-1Jr PHONE��-73 1 ], <br /> SUBCONTRACTOR ADDRESS CIT-Y7/STATE/ZIP /!� <br /> LICENSE C-57 E]C-61 ❑D-09 ❑Other NUMBER-A / �f EXPIRATION DATE p 17 <br /> DOMESTIC WELL SAMPLING:❑General Mineral/Coliform Bacteria (4391)❑Dibromochloropropane(4392)❑Arsenic(4393) <br /> INTENDED USE ❑Domestic/Private errigation/Ag ricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization <br /> ❑Public Water System <br /> If different from Owner: Water System Name L;ontact Name or Phone Number <br /> TYPE OF WORK ')?j<ew Well ❑Replacement Well [-)Well Alteration/Modification ❑Other <br /> ❑Monitoring Well(s) #of wells ❑ #of borings SoilBoring(s) ❑Geotechnical #of borings <br /> F-1 Out-Of-Service Well ❑Out-Of-Service Well Renewal []Cross-Connection Repair <br /> ew Pump ❑Pump Replacement ❑Pump Repair ❑Raise Well Casing <br /> WELL CONSTRt<TION <br /> Drilling Methodud Rotary El Air Rotary ❑Auger ❑Cable Tool E]Push Point ❑ Other <br /> Proposed Well Depth !£ ft Excavation in diameter E]Open Bottom ravel Pack/Gravel Size in diameter <br /> F]Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter J3-- in Thickness/Gauge/ASTM Sched'7 j&-D ❑Steel Plastic ❑Stainless Steel ❑Other <br /> Grout Seal Depth :570 ft ❑Neat Cement(94 lb bag/5-10 gal water) Sand Cement ly r sack mix17 gal water <br /> ❑Bentonite(20%solids) ❑Other <br /> Grout Placement Method Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By 4E!�briller ❑Pump Contractor ❑ Other <br /> ❑Concrete Pedestal Epimensions:Width Zft Length ft Thick in ❑Christy Box ❑Stove Pipe <br /> PUMP submersible❑Turbine ❑Other HP_1_0 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 L!CENSE BOARD AND THAT I AM IN COMPLIANCE :".ITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MIN�4 HQUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 9y53-7697 <br /> SIGNED �OL. TITLE �� DATE Z 2- T- / <br /> a�� <br /> � ED <br /> 1 016 <br /> Utz- <br /> uNry <br /> A T N L <br /> Eftr <br /> t <br /> L <br /> 0rARTMENT SE ONLY <br /> Application Accepted Date ZI L17 1 Area Employee ID#1 � <br /> Grout Inspectio B C� Date �{ ❑ PECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> 1AAltf- U5 - Te(- M;T1 <br /> PE Sc Received h!5k#1> Amount Date Permit/ Invoice# Well ID# <br /> Codes nfo Ay ---Gash Remitted Service Request# <br /> 1 D 00,31 <br /> �° z S12U0 Ob 3 <br /> EHD 43-06 8101116 WELL/PUMP PERMIT <br />