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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 /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> 5 <br /> JOB ADDRESS 'Y ✓/-n !�D c' CITY/ZIP / m <br /> D <br /> /h Ik? ��C� APN Z!-3 _/70 <br /> CROSS STREET Pf �� PARCEL SIZE/ZZ' AND USE APPLICATION# A <br /> OWNER NAME � Ci�f t`l�A J/r�J`'y/TQn [��j� PHONE <br /> OWNER ADDRESS /'L/�fJ f'Ui�l! hWV� n �J CITY/STATE/ZIP <br /> y (� <br /> CONTRACTOR ) L rr�((}h lam(/']��Ih/ / 2 / /T'���/SC7 61 PHONE-2-0 <br /> -I `r G' <br /> CONTRACTOR ADDRESS O 1l- I rI1 I �ll 7 CITY/STATE/ZIP /�}�fes/ / <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE AC-57 ❑ C-61 1-1D-09 11Other NUMBER G�goo 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 Lwtoil Sampling/Characterization <br /> ❑ Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK ❑ New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other <br /> ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings Geotechnical #of borings <br /> Cl Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair 26 <br /> ❑ New Pump ❑ Pump Replacement Cl Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method ❑ Mud Rotary ❑ Air Rotary [/Auger 1.1 Cable Tool ❑ Push Point ❑ OtherMAW <br /> , <br /> Proposed Well Depth 20­50 ft Excavation W& il) in diameter I i Open Bottom ❑ Gravel Pack/Gravel Size in diameter <br /> ❑ 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 lb bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water <br /> ❑ Bentonite(20%solids) ❑ Other <br /> Grout Placement Method ❑ Pumped ❑ Free Fall Other F1 Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other <br /> ❑ Concrete Pedestal ❑Dimensions:Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe <br /> PUMP ❑ 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 /> MINIMUM 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br /> J 7 <br /> SIGNED �j ` ( TITLE &colo/S� DATE lV 30—/9 <br /> DEPA TMENT USE ONLY <br /> Application Accepted By Date � U _ Area Employee ID#� <br /> Grout Inspection By \ Da74X te 1�1(I'g ❑ SPECIAL W21i Perrrii <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info Remitted Service Request# <br /> ' 0 s 2018 <br /> ENV RONMENTAL <br /> HEA <br /> EHD 43-06 8/01/16 WELL/PUMP PERMIT <br />