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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 FR9M DATE ISSUED <br /> JOB ADDRESS l i � � pp ////__ N <br /> 1 . r CITY/ZIP l��i 1� l7 —1 <br /> �\- m <br /> CROSS STREET v� � „j APN 0o� 2'3 14 PARCEL SIZE )f LAND USE APPLICATION# v <br /> OWNER NAME C� + PHONE Ch <br /> OWNER ADDRESS \ y� ��y \V CITY/STATE/ZIP -_ 1 <br /> CONTRACTOR t— - V �L L PHONE q- f <br /> CONTRACTOR ADDRESS enx CITY/STATE/ZIP w t LQ1�4 , CA <br /> SUBCONTRACTOR 11 PHONE <br /> SUBCONTRACTOR ADDRESS C <br /> `I <br /> ITTY/STATE/ZIP <br /> LICENSE C-57 El C-61 E]D-09 [:1 Other NUMBERjIJ /LTL EXPIRATION DATE I <br /> DOMESTIC WELL SAMPLING:XGeneral Mineral/Coliform Bacteria (4391)❑Dibromochloropropane (4392)❑Arsenic(4393) <br /> INTENDED USE Domestic/PrivatelcragatieAlAgFietti#tlrat ❑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 )qNew Well ❑Replacement Well ❑Well Alteration/Modification E]Other <br /> ❑Monitoring Well(s) #of wells ❑Soil Boring( ) ❑Geotechnical S #of borings #of borings <br /> F]Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> New Pump ❑Pump Replacement ❑Pump Repair ❑Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method ❑Mud tar ❑ ❑ <br /> Air Rotary Auger [ ❑ E]able Tool Push Point Other <br /> Proposed Well Depth-7 ft Excavation in diameter XOpen Bottom [-]Gravel Pack/Gravel Size in diameter <br /> ❑ConductCasing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter 6 in Thickness/Gauge/ASTM Sched ( Steel ❑Plastic ❑Stainless Steel ❑Other <br /> Grout Seal Depth I06 ft ❑Neat Cement(94 Ib 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 ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑ Other <br /> E]Concrete Pedestal Epimensions:Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe <br /> PUMP ubmersible❑Turbine ❑Other HP Pump Set ft Standing Water Level 1&0 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 OUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br /> SIGNED TITLE KtM r I}D(2, DATE <br /> 1 <br /> z <br /> t3 iti <br /> c> f <br /> WT <br /> W <br /> n _I <br /> it <br /> DEARTMENT SE N L Y <br /> Application Accepted By Date ZS Area LklEmployee ID#CJI �D <br /> Grout Inspection By -'e'ey Ah7ncefDate /7 ❑ PECIAL Well Permit <br /> Pump Inspection By Date 0 ❑ WAIVER Received 7 �/ <br /> Soil Boring Inspection By Date Constructed Well Depth 33 ,K 0 ft <br /> COMMENTS <br /> PE Sc Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Cod.es, Info By Cash Remitted Seryice Re uest# <br /> ( NDT -7 A-1 V,400 . 00q <br /> o 7-z - 6 <br /> tc <br /> EHD 43-06 8/01/16 WELL/PUMP PER <br />