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Znlhal SC�n �+jlq Ile� <br /> ' WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 <br /> N ON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> 113 A � <br /> r JOB ADDRESS r CITY/ZIP �- • 0 U m <br /> S D <br /> CROSS STREET A.&' yV&,nA ir15 APN '�� 0 �- I PARCEL SIZ����r L D USE APPLICATION# S <br /> d <br /> OWNER NAME 6 S brA Oil d 1r_er "W 1 r an I PHONE 7- 3 C Q (n <br /> Qur <br /> OWNER ADDRESS CITY/STATE/ZIP � <br /> CONTRACTOR y1``�� F �All S"s /� 1. 'PHONNE L !J [• V /))2_ ' <br /> CONTRACTOR ADDRESS �U Y✓y-/ -7 CITY/STATE/ZIP <br /> SUBCONTRACTOR �C.t>et�I�-' PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE ,91;-57 ❑C-61 ❑D-09 ❑Other NUMBER 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 System Name Uontact Name or Phone Number <br /> TYPE OF WORK ',441N ew Well ❑Replacement Well ❑Well Alteration/Modification El Other <br /> El Monitoring Well(s) #of wells El Soil Boring(s) #of borings ❑Geotechnical #of borings <br /> F1 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 CONSTRU TION <br /> Drilling Method.&ud Rotary E]Air Rotary ❑Auger ❑Cable Tool E]Push Point ❑ Other <br /> Proposed Well Depthr rr ft Excavation in diameter ❑Open Bottom Gravel Pack/Gravel Size in diameter <br /> ❑Conduct r Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter R in Thickness/Gauge/ASTM Sched�t:' E]Steel �lastic [:]StainlessSteel F]Other <br /> Grout Seal Depth � ft E]Neat Cement(94 Ib bag/5-10 gal water) and Cement 0 a � sack mix/7 gal water <br /> ❑Bentonite(20%solids) ❑Other <br /> Grout Placement Method4:TPumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By riller E]Pump Contractor ❑ Other <br /> E]Concrete Pedestal Epimensions:Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe <br /> PUMP ubmersible❑Turbine ❑Other HP 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 /> MINIMU 24 H UR VANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209)),953-769/7 <br /> SIGNED �� TITLE { [��Iti DATE d '/ <br /> - - - - <br /> f. Y <br /> yy r� Ul <br /> U <br /> Z <br /> IV <br /> 5)z <br /> e r <br /> o <br /> DEAPARTMENT SE ONLY <br /> Application Accepte dn,,' DQ IA C ate9h Area Employee ID#� <br /> Grout Inspection By Date ❑ PEC AL Well Permit <br /> Pump Inspection By Date t7' ' ❑ WAIVER Received <br /> Soil Boring Inspection By constructed Well Depth ft <br /> t;OMMENTS ` `{ C� piyri. � cw t fHi d d ©��!$ <br /> PE SC Received Check#/ Amount Permit/ <br /> Codes Info B Cash emitted Date Service Request# Invoice# Well ID# <br /> 3 saroa <br /> U• �aq4 W DO gkis <br /> EHD 43-06 8101/16 WELL/PUMP PERMIT <br />