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WELL/PUMP PERMIT /4' <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1 865 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)465-3420 <br /> NON-REFUNDABLE PERMIT 209 953-7697 FO NSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> 106 ADDRESS L� �✓,f ��J y��1 S �d,7 CITY/ZIP �f�' m <br /> CROSS STREET �� V✓ � r"� APN �/o LS 613 PARCEL SIZE �LA D USE APPLICATION# v <br /> ,OWNER NAME 1 A b ''V`Q-U'1 N tic C� PHONE y <br /> OWNER ADDRESS �I 1/STATE/ZIP ca .C/� / <br /> CONTRACTOR 1=-11 / )PHON[EE ::s 3 -/,7 <br /> CONTRACTOR ADDRESS o IV�(�n�/� CITY/STATE/ZIP <br /> y� / <br /> SUBCONTRACTOR 1e&) [ �'1 V/�� (/I"r PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP / <br /> LICENSE C-57 ❑C-61 ❑D-09 ❑Other NUMBER "S') 73 a EXPIRATION DATE <br /> DOMESTIC WELL SAMPLING:❑General Mineral/Coliform Bacteria (4391)❑Dibromochloropropane (4392)❑Arsenic(4393) <br /> INTENDED USE Pwomestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring El Soil Sampling/Characterization <br /> ❑Public Water System <br /> If different from Owner: Water bystem Name Contact Name or Phone Number <br /> TYPE OF WORK Fjoeew Well ❑Replacement Well ❑Well Alteration/Modification ❑Other <br /> ❑Monitoring Well(s) #of wells ❑Soil Boring(s) #of borings #of borings <br /> ❑Geotechnical <br /> L]Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> ew Pump ❑Pump Replacement ❑Pump Repair ❑Raise Well,Casing <br /> WELL CONSTRUCTION <br /> Drilling Method,)�Wud Rotary ❑Air Rotary ❑Auger ❑Cable Tool E]Push Point ❑ Other <br /> Proposed Well Depth!s20ft Excavation L in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter <br /> ❑Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter 6' in Thickness/Gauge/ASTM Sched*7-0 E]Steel Plastic E]Stainless Steel ❑Other <br /> Grout Seal Depth_X 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 3ebriller El Pump Contract r ❑ Other <br /> E]Concrete Pedestal❑pimensions:Width ft Length ft Thick in [-]ChristyBox ❑Stove Pipe <br /> PUMP XSubmersibleElTurbine ❑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 /> MINIM X24 OUR <br /> /�VANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 9953-7+697 �t <br /> SIGNED t .,.[i(RG _'/L��— TITLE DATE (J / —Z l� <br /> �r <br /> v <br /> c <br /> 8 <br /> P T M E N T U E NLY <br /> Application Accepted By nate Area Employee ID#� <br /> Grout Inspection By Date � Z 2 Ott j SPE IAL Well Permit <br /> Pump Inspection By hh <br /> Date V l ❑ WAIVER Received <br /> i <br /> Soil Boring Inspection B Dat7j4� 10. Constructed Well Dept�yh i�L7 ft <br /> COMMENTS fll 1 1 <br /> PE Sc Received Amount ate Permit/ Invoice# Well ID# <br /> Codes fo B ash Re fitted Service Request# <br /> 8 P1 Z <br /> EHD 43-06 8/01/16 WELL/PUMP PERMIT <br />