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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 /> 57 3 ` <br /> Ln <br /> ADDRESS CITY/ZIP C/A q�Gzo <br /> D <br /> CROSS STREET —!61n APN ®� ��,�® 50 PARCEL SIZE. AND USE APPLICATION# <br /> OWNER NAME —lLLll.Yl tD ML (Sl tG"X� I Y 11i! /� PHONE �� /� /� <br /> OWNER ADDRESS � W CITY/STATE/ZIP A-eA too e `/ 5 <br /> CONTRACTOR ✓�'� 0��{/1 �L F ,lP'HONE <br /> CONTRACTOR ADDRESS � � � G1csG1 CITY/STATE/ZIP Ll"c�> ���'rvtc,j C777 G 5� <br /> SUBCONTRACTOR PHONE ,-/ �` - Z 75 <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE C-57 [I C-61 F1 D-09 LI Other NUMBER EXPIRATION DATE !a-3/ <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 Contact Name or Phone Number <br /> TYPE OF WORK ❑ New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other PAYAR <br /> ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings CI Geotechnical <br /> ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> New Pump ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casing 1 <br /> WELL CONSTRUC ION <br /> Drilling Method ❑ Mud Rotary Ll Air Rotary El Auger ❑ Cable Tool LI Push Point L1JOAQ <br /> Other SAN <br /> UIN Cnr�.,__ <br /> M <br /> Proposed Well Depth ft Excavation in diameter F1 Open Bottom L-1GravelPack/GravelIeALT E,�Trneter <br /> ❑ Conductor Casing in diameter / Conductor Casing Depth ft "MEN7' <br /> Well Casing Diameter_ in Thickness/Gauge/ASTM Sched ❑ Steel ❑ Plastic F1 Stainless Steel ❑ Other <br /> Grout Seal Depth ft 1.1 Neat Cement(94 lb bag15-10 gal water) ❑ Sand Cement sack mix17 gal water <br /> ❑ Bentonite(20%solids) I1 Other <br /> Grout Placement Method ❑ Pumped ❑ Free Fall LI Other ❑ 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 SubmersibleLI Turbine 1-1 Other HPPump 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 /> MINIMU ADVANC ICE REQUIRED �OR INSPECTIONS - PLEASE CALL (209) 953-7697 <br /> SIGNED T IE� <br /> TLC �O DATE / <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date L Area 1 Employee ID#� ✓l�-_4 <br /> Grout Inspection B \ p�` Date CI SPECIAL Well Permit <br /> Pump Inspection By IV t1�T_1 `���1�\IV Date Z L I WAIVER Received <br /> Soil Boring Inspection By Date �J Constructed Well De th ft <br /> COMMENTS / v i Y `'t d r C-)A <br /> �� <br /> PE SC Receivedhe Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B s Remitted Service Request# <br /> EHD 43-06 8/01/16 WELL/PUMP PERMIT <br />