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s <br /> WELL/PUMP PERMIT <br /> SAN JOAQUIN'COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 <br /> NON-REFUNDABLE PERMIMITT/ /CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM/DATE ISSUED <br /> JOB ADDRESSm <br /> �✓"/ / ! c�l'/�/•'�y-t__ /'i' CITY/ZIP <br /> �� D8 �.03,5 <br /> CROSS STREET AJPN� �� / PARCEL�SIZEt l�LAND SE APPLICATION# <br /> /v f jY/�'�' Cn <br /> OWNER NAME J I i� /� �� /�/�/r�lla---�" InYll, Ej�T"� O / (/%() <br /> OWNER ADDRESS Ate¢ y-�,/� �,�-s CITY/STATE/ZIP <br /> CONTRACTOR L%C DD/ //����l Ay7' rZ Cp/.�+�E7�r PHONE <br /> CONTRACTOR ADDRESS -2 �O �/� O� CITY/STATE/ZIP <br /> SUBCONTRACTOR �— PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE -57 -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: Water System Name Uontact Name or Phone Number <br /> TYPE OF WORK E]New Well El Replacement Well ❑Well Alteration/Modification ❑Other <br /> ❑Monitoring Well(s) #of wells ❑Soil Boring(s) #of borings ❑Geotechnical #of borings <br /> ❑Out-Of-Service Well E]Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> ❑New Pump MumpReplacement ❑Pump Repair ❑Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method ❑Mud Rotary []Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑ Other <br /> Proposed Well Depth ft Excavation in diameter E]Open Bottom ❑Gravel Pack/Gravel Size in diameter <br /> F-1 Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑Steel ❑Plastic ❑Stainless Steel ❑Other <br /> Grout Seal Depth ft ❑Neat Cement(94 Ib bag/540 gal water) ❑Sand Cement sack mix/7 gal water <br /> ❑Bentonite(20%solids) ❑Other <br /> Grout Placement Method [:]Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑ Other <br /> E]Concrete Pedestal dimensions:Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe <br /> PUMPubmersible❑Turbine ❑Other HP F 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 COMP NSATION LAWS. <br /> MINI A NOTICE REQUIRED FORINS ECTIONS - PLEASE LL (209) 953-i7997 <br /> SIGNED '�� TITLE DATE <br /> iod <br /> AV <br /> ij <br /> Tit`l f <br /> DE ARTMENT U E N L Y <br /> Application Accepted B ` Date Area Employee ID# lao., j <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Purip Inspection By - Date " ❑ WAIVER Received <br /> SOii Bcriny inspection By Date_ _ Constructed Well Denth ft <br /> COMMENTS <br /> PE SC Received Check#/ Amount Permit/ <br /> Co s Info B Cash Remitted Date Service Request# Invoice# Well ID# <br /> S? e 5206 7 7 003 I <br /> _J <br /> EHD 43-06 8/01/16 VJELL/PUM'PERMIT <br />