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xAffe TnihalScan <br /> cut' it: 5s f WELL/PUMP PERMIT <br /> . SAN JOA IN COUNT', Er, ..ONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 <br /> NON <br /> -REFUNDABLE PERMIT CALL(2 99)953-7697 FOR INSPECTIONS E PIRES 1 YEAR FROM DATE ISSUED <br /> -- 9 T n N <br /> v .JOB ADDRESS ,L, '�� 'l /' �j�,(� I'� CITY/ZIP 1 m <br /> CROSS STREET V PARCEL SIZE LAND USE APPLICATION# S <br /> ,n �j m <br /> OWNER NAME Y Gj AalL' Alt/si— L bco �� PHONE Z �+~9,53 U) <br /> �i <br /> OWNER ADDRESS A�� v C-VL- l/�M/ CITY/STATE/ZIP / �r <br /> CONTRACTOR � r ., ' k� r �l -PH/ONE q�Z a <br /> CONTRACTOR ADDRESS °,7j-% CITY/STATE/ZIP/j_j000�/(�r-11V/Y�9b <br /> SUBCONTRACTOR 1!I(A/��F�— PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE T -57 [I C-61 [I D-09 ❑ R <br /> Other NUMBER <br /> 7 ?�' EXPIRATION DATE <br /> DOMESTIC WELL SAMPLING:[-]General Mineral/Coliform Bacteria (4391)❑Dibromochloropropane(4392)❑Arsenic(4393) <br /> INTENDED USE ❑Domestic/Private rrigation/Agricultural ❑Industrial [:]Water Quality Monitoring ❑Soil Sampling/Characterization <br /> ❑Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK-.4New Well ❑Replacement Well ❑Well Alteration/Modification ❑Other <br /> El Monitoring Well(s) #of wells ❑ #of borings Soil Boring(s) ❑Geotechnical #of borings <br /> F1 Out-Of-Service Well ❑Out-Of-Service Well Renewal E]Cross-Connection Repair <br /> >4�4ew Pump ❑Pump Replacement ❑Pump Repair ❑Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method R3 lud Rotary ❑Air Rotary ❑Augery ❑Cable Tool El Push Point ❑ Other <br /> Proposed Well Depth 7, <br /> c=�ft Excavation / in diameter E]Open Bottomravel Pack/Gravel Size in diameter <br /> E]Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in T ' ess/Gauge/ASTM Sched A 1'i 1 ❑Steel Plastic E]Stainless Steel E]Other <br /> Grout Seal Depth �* ��❑Neat Cement(94 lb bafg/b-10`gall water) Sand Cement sack mix17 gal water <br /> E]Bentonite(20%solids) ❑Other <br /> Grout Placement MethodA4Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By ;[Driller ❑Pump Contractor ❑ Other <br /> --- <br /> E]Concrete Pedestal dimensions:Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe <br /> PUMP >ggSubmersible❑Turbine ❑Other HP 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 24 HOUR DVANCE NOTICE REQUIRED FOUR INSPECTIONS - PLEASE CALL (209)(9y53-7697 <br /> SIGNED TITLE g ` iJ 9s�6 DATE 7" ~1 r� <br /> r <br /> J <br /> Q <br /> U <br /> Z <br /> U <br /> ACX <br /> z� <br /> r / <br /> � I <br /> i <br /> � I I <br /> J <br /> DEPARTMEN*UE NLYApplication Accepte DateArea Employee ID#Grout Inspection By / Date E] SPECIALWell Permit <br /> PUmp Inspection By C ataU r._' WAIVER Received <br /> Soil Boring. In ection By Cate_ _ Constructed Well Depth <br /> COMMENTS ;V�LaSG✓N_- <br /> "o S G" Y'i1 ' <br /> W hi t� „�Ftl " � <br /> PE Sc. I R�S3".cd 7�ck- ; Amount ermit/ <br /> Codes nfo B _Gash emitted Date Service Request# Invoice# WeG ID# <br /> 1 -5 Satz VOMMOV2 ` <br /> I <br /> EHD 43-06 8/01/16 WELL/PUMP PERMIT <br />