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/1447 <br /> ✓�cU WELL/PUMP PERMIT <br /> SAN JCAQUIN COUNTY ENVIRONMENTAL 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 ��.� /� ' CITY/ZIPC��t `�L� m <br /> CROSS STREET O f] /�4 /✓Y��� [�f- APN - o-/ PARCEL SIZE /16 USE APPLICATION# A <br /> OWNER NAME (✓/j //�,�. ���yrCS � � Y�✓7 LYA PHONE J L m <br /> "� <br /> OWNER ADDRESS /w�/-►� CITY/STATE/ZIP o t <br /> CONTRACTOR171IPHGO,NE �S 7/�► 7y� <br /> CONTRACTOR ADDRESS /J �7 U7V L (�1 CITY/STATE/ZIP ��W/ / } � <br /> SUBCONTRACTOR PHONE / <br /> SUBCONTRACTOR ADDRESS CITY/ST <br /> A <br /> T <br /> E <br /> /ZIP <br /> LICENSE yOC-57 ❑C 61 ❑D-09 ❑Other NUMBER� 7-7:38S✓ EXPIRATION DATE <br /> DOMESTIC WELL SAMPLING:❑General Mineral/Coliform Bacteria (4391)❑Dibromochloropropane(4392)❑Arsenic(4393) <br /> INTENDED USE omestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sam pli ng/Characteriz2tion <br /> ❑Public Water System <br /> If different from Owner: Water System Name Uontact Name or Phone Number <br /> TYPE OF WORK >New Well ❑Replacement Well ❑Well Alteration/Modification ❑Other <br /> El Monitoring Well(s) #of wells E]Soil Boring #of borings s) ❑Geotechnical #of borings <br /> F-1 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 MethodsRMud Rotary ❑Air Rotary ❑Auger ❑Cable Tool E-]Push Point ❑ Other <br /> Proposed Well Depth o ft Excavation _ E`2__ in diameter El Open Bottom 'ravel Pack/Gravel Size in diameter <br /> F]Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM SChed,7 El Steel ,Q-Plastic E]Stainless Steel ❑Other <br /> Grout Seal Depth Llav ft ❑Neat Cement(94 Ib bag/5-10 gal water) " <br /> > Sand Cement 141?.'141?.' } sack mix/7 gal water <br /> ❑Bentonite(20%solids) ❑Other / <br /> Grout Placement Method JerPumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By 'ruler ❑Pump Contractor, El Other <br /> El Concrete Pedestal dimensions:Width C ft Length ft Thick--_-A in ❑Christy Box ❑Stove Pipe <br /> PUMP Submersible❑Turbine ❑Other HPC_ Pump Set ft Standing Water Level ft <br /> 1 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 /> MINIM M 24,HOW ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br /> SIGNED 'i/ z' TITLE OL� � DATEf—t000 <br /> r <br /> RZ <br /> 10 <br /> AJ 1 <br /> Y1 <br /> 1 <br /> E VI O M NT ,L T <br /> H TH D <br /> D PARTMENT USE ONLY <br /> Application Accepted By - Date Area " 1 Employee ID05:q C l7 <br /> Grout Inspectio y - t Date ❑ SPECIAL Well Permit <br /> Pump Inspection By Date W 11 ❑ WAIVER Received <br /> Soil Boring Inspection By pp Date Constructed Well Depth <br /> COMMENTS e {�tOZN C i���?iOT_ �O �i :M' Alwf 90 m <br /> �. <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B Cash Remitted Service Reque t# <br /> U <br /> p o <br /> UO3�b 8 <br /> v p <br /> 13 7 'ot 'O rq s <br /> EHD43-06 8/01/16 d0 �rSN 5 F¢-� WELL/PUMP PERMIT <br />