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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 <br /> 9ON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIR S 1 YEAR FROM DATE ISSUED <br /> ?B ADDRESS ��j�� � l��/f � CITY/ZIP I, r m <br /> CROSS STREET T/�x' Y`' APN� PARCEL <br /> SIZE LAND USE APPLICATION#�r��'` <br /> OWNER NAME �(J�/fj� /� �� /-atm r�i /�/�j PHONE�7~WVy rn <br /> �r D� rn <br /> OWNER ADDRESS L % 13 13 kJ I/U� r Y CITY/STATE/ZIP LoC7// /v <br /> CONTRACTOR / A� �{�^L '� PHONE 37 / <br /> f'— <br /> CONTRACTOR ADDRESS /tet✓ I �k� CITY/STATE/ZIP e Z A <br /> SUBCONTRACTOR r�iO$f � PHONE+, `�1-2-0 <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE (<C-57 ❑C-61 ❑D-09 ❑Other NUMBER EXPIRATION DATE 7b <br /> DOMESTIC WELL SAMPLING:[-]General Mineral/Coliform Bacteria (4391)❑Dibromochloropropane (4392)❑Arsenic(4393) <br /> INTENDED USE omestic/Private ❑Irrigation/Agricultural ❑Industrial [:]Water Quality Monitoring E]Soil Sampling/Characterization <br /> ❑Public Water System <br /> If different from Owner: Water bystern Name Contact Name or Phone Number <br /> TYPE OF WORK ew Well ❑Replacement Well ❑Well Alteration/Modification E]Other <br /> ❑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 /> "FrNew Pum El Pump Replacement El Pump Repair ❑Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Methoo><[M..u�ddj..R��,,o�ttaary ❑Air Rotary ❑Auger [:]CableTool El Push Point El Other <br /> Proposed Well Depitz— ft Excavation in diameter ❑Open Bottom WGravel Pack/Gravel Size in diameter <br /> E]Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter A67 in Thickness/Gauge/ASTM Sched-1-7;> _ ❑Steel ;Olastic ❑Stainless Steel ❑Other <br /> Grout Seal Depth-1 L*.jj0*ft ❑Neat Cement(94 Ib bag/5-10 gal water) Sand Cement k. 3 sack mix/7 gal water <br /> ❑Bentonite(20%solids) ❑Other <br /> Grout Placement Method 0sumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By >0riller E]Pump Contractor ❑ Other <br /> El Concrete Pedestal dimensions:Width ft Length ft Thick in [:]ChristyBox ❑Stove Pipe <br /> PUMP 16 Submersible❑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 /> MINIM 24 OUAA ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209)/9s53-7697 <br /> SIGNED C� TITLE �f.�/ps— DATE <br /> 1 <br /> Wk <br /> O <br /> v1h OAH <br /> A M <br /> EPA TMENT U E ON Y <br /> Applic tion Accepted By Date Area Employee ID# <br /> Gr t Inspection ByAVTDate �" ❑ SPECIAL Well Permit <br /> Pum Inspection By ( ?- Date! T ❑ WAIVER Received <br /> Soil Boring Inspection By t7 Date Constructed Well Depth 71D# ft <br /> COMMENTS� Lz �(C9 I ��- �Jy�/•[�S //(� _��' '�C�• �n/�C��� f1 3PE SC Received Check# Amount Date Permit/ Invoice# Wel <br /> Codes Info B Remitted Service Request# <br /> l o-1 S PfU UW 00 <br /> l.3 7Sk)() I &T4 vifK7PI"I&'1 <br /> EHD 43-06 8/01/16 WELL/PUMP PERMIT <br />