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an i h a l Scan '�+l►q <br /> l WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-76/97G FOR INSPECTIONS EXPIRES 'I YEAR FROM DATE ISSUED <br /> r JOB ADDRESS , // ' CITY/ZIP • m <br /> �`�r, D <br /> CROSS STREET Z&—J/tK APN PARCEL Sid!Vb" D USE APPLICATION# <br /> OWNER NAME D V) J� e I r fEff PHONE�� 7 Cn <br /> Q^1 ur <br /> OWNER ADDRESS \ /�1�- / \ CITY/STATE/ZIP <br /> CONTRACTOR - )�+�.` On" Z `d.PHO/NE 3 '.�? <br /> CONTRACTOR ADDRESS <br /> TCITY/STATE/ZIP <br /> SUBCONTRACTOR ✓'l L'­j rz PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE , kr-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 ❑Dom estic/Private,><rrigation/Ag ricultural ❑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 WORK1QIVew Well E]Replacement Well ❑Well Alteration/Modification E]Other <br /> ❑j Monitoring Well(s) #of wells ❑Soil Boring(s) #of borings #of borings <br /> ❑Geotechnical <br /> F]Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> ` ew Pump ❑Pump Replacement ❑Pump Repair ❑Raise Well Casing <br /> WELL CONSTRU TION <br /> Drilling Metho4-&ud Rotary El Air Rotary []Auger ❑Cable Tool E]Push Point ❑ Other <br /> Proposed Well Depth ft Excavation in diameter ❑Open Bottom ,Gravel Pack/Gravel Size in diameter <br /> ❑Conduct rr Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter «Y� ir1 Thickness/Gauge/ASTM Sched�'�� El Steel �'lastic E]Stainless Steel ❑Other <br /> Grout Seal Depth ft ❑Neat Cement(94 Ib bag/5-10 gal water) and Cement 'I�. sack mix17 gal water <br /> ❑Bentonite(20%solids) ❑Other <br /> Grout Placement Method4:�Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed Byi;?;'—Driller ❑Pump Contractor ❑ Other <br /> ❑Concrete Pedestal Epimensions:Width ft Length ft Thick in ❑Christy Box []StovePipe <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. 1 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 ApDVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953--y769/7 <br /> SIGNED ��� �� TITLE f jj A l� DATE /"/ 7 <br /> -s <br /> U <br /> LLi <br /> Z <br /> 0- <br /> I�D PARTMEN*EO Y(IIAA11K r-1 <br /> Application Accepte DateArea Employee ID#� <br /> Grout Inspection By Date ❑ PEC AL W811 Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection By constructed Well Depth ft <br /> UOMMENTS �)"-( �c,c( IwT_ <br /> SC Received Check#/ Amount Permit/ <br /> [�OP�:E <br /> s Info B Cash emitted Date Service Request# Invoice# Well ID# <br /> 3 51Z 06-1W4�� poo <br /> W Coo 3 ol¢S <br /> EHD 43-06 8/01/16 WELL/PUMP PERMIT <br />