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" Z V114'kk 5(.wn 11-5- 1(-) OyK' <br /> WELL/PUMP PERMIT <br /> ySAN JOAQUIN 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 /> rn <br /> JOB ADDRESS •� 1 / CITY/ZIP m <br /> , / q D <br /> CROSS STREET Z/L APN 00`� 140 ' 4 PARCEL SIZE'S all USE AAPPLICATION# A <br /> OWNER NAME /V � U(J/v-J `-,Lnn LI � P 9/ PHONE • r "�-�S� N <br /> / i Y/TATE ZIP ' <br /> OWNER ADDRESS r✓�/I <br /> CI <br /> CONTRACTOR �PHONE �_ <br /> CONTRACTOR ADDRESS 1W CITY/STATE/ZIP `"� '�•��� <br /> SUBCONTRACTOR jf�?Oa ��c� /�fQ ,✓(/j4� PHONE��� <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP C <br /> LICENSE SCC-57 El C-61 ❑D-09 ❑ '57-73Other NUMBER �y EXPIRATION DATE 3-0 1-7 o-30 <br /> DOMESTIC WELL SAMPLING:[-]General Mineral/Coliform Bacteria (4391)❑Dibromochloropropane(4392)❑Arsenic(4393) <br /> INTENDED USE ❑Domestic/Private Irrigation/Agricultural ❑Industrial E]Water Quality Monitoring E]Soil Sampling/Characterization <br /> ❑Public Water System <br /> If different from Owner: Water bystem Name Contact Name or Phone Number <br /> TYPE OF WORK 4New Well ❑Replacement Well ❑Well Alteration/Modification E]Other <br /> El Monitoring Well(s) #of wells ❑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 CONSTRU TION <br /> Drilling Method<Mud Rotary E]Air Rotary ❑Auger ,❑Cable Tool El Push Point ❑ Other <br /> Proposed Well Depth 44�SZ� ft Excavation 1 in diameter E]Open Bottom *ravel Pack/Gravel Size in diameter <br /> ❑Conductt Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter (3 in Thickness/Gauge/ASTM Sched ❑Steel Plastic E]Stainless Steel ❑Other <br /> Grout Seal Depth C ft ❑Neat Cement(94 lb bag/5-10 gal water) >Ksand Cement sack mix17 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 /> PUMP AaSubmersibleElTurbine ❑Other HP ED 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 /> MI UM 4 H UR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br /> SIGNED _ K.- TITLE �C�.�aaf2 DATE <br /> q <br /> Q � A <br /> s N a <br /> EP RTMENT USE ONLY <br /> � O <br /> Application Accepted & Date Area Employee ID# <br /> Grout Inspection By r Date ❑ SPECIAL Well Permit <br /> Pump Inspection By L4 1 Date ❑ WAIVER Received <br /> Soil Boring spection By Date Constructed Well Depth <br /> COMMENTS d G <br /> PE SC Received Check#I Amount Date Permit] Invoice# Well ID# <br /> Codes Ifo B Remitted Service Request# <br /> 3 —w—PM-R79 <br /> VROMI <br /> EHD 43-06 8/01/16 WELL/PUMP PERMIT <br />