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. n <br /> WELL/PUMP PERMIT Ed SAN.TOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 952 5 - ) 6 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> m <br /> JOB�.:1DRESS CITYIZIPTkA e � <br /> m <br /> 1 i 1 /J D <br /> CROSS STREET I i ! O C/Y1PN /�.SZ ©©� PARCEL SIZE � LAND USE A�P`PLICATION#r A <br /> OWNER NAME �C Z ` � P O E a7 fD �7 ���� co <br /> OWNER ADDRESS n:35, <br /> tQS �! &V0P`t;1P6 ATE/ZIP �D J <br /> �J / /e- <br /> CONTRACTOR C t(� /� I D.q `G PHONE 7 6 �S/�- !S �Z. <br /> CONTRACTOR ADDRESS 30o v. /�i./'VJ 4( CITY/STATE/ZIP IAC o/�ch, `d. '7S_--?76 <br /> I �— <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE fe-C-57 11C-61 11D-09 CI Other NUMBER t1aj3y(2) EXPIRATION DATE-0 - <br /> DOMESTIC WELL SAMPLING: I_ General Mineral/Coliform Bacteria (4391) 1 1 Dibromochloropropane(4392) I I Arsenic(4393) <br /> INTENDED USE omestic/Private ❑ Irrigation/Agricultural ❑ Industrial I I Water Quality Monitoring ❑ Soil Sampling/Char jpq <br /> ❑ Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Numbel4ft , <br /> TYPE OF WORK New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other Orr <br /> ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings LI Geotechnicaco o <br /> ., VQ ?�D <br /> ❑ Out-Of-Service Well 11 Out-Of-Service Well Renewal 11 Cross-Connection Repair�tA( / U/NCO <br /> 11 New Pum Li Pum Replacement 11 Pum Repair ❑ Raise Well CasingOUN <br /> WELL CONSTRUCTION l'AftkENT <br /> Drilling Method AeGd Rotary 11Air Rotary ❑ Auger ❑ Cable Tool 11 Push Point ❑ Other <br /> 1 <br /> Proposed Well Depth %l01 ft Excavation �O/Yin diameter I1 Open Bottom 6,Gravel Pack/Gravel Size R' in diameter <br /> ❑ Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched JO.RV ❑ Steel L'�astic ❑ Stainless Steel ❑ Other <br /> Grout Seal Depth />� ft 1-1 Neat Cement(94 lb bag/5-10 gal water) Li Sand Cement sack mix/7 gal water <br /> Q t3entonite(20%solids) ❑ Other <br /> Grout Placement Method 9ru—mped ❑ Free Fall F1 Other 11 Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller 0#15ump Contractor ❑ Other <br /> ❑ Concrete Pedestal ❑Dimensions:Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe <br /> PUMP ubmersible❑ 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 OMPENSATION LAWS. <br /> M IM OUR ADVANCE NOTICE REQUIRED FOR INSPEC�TPNS -PLEASE CALL (209) 953-7697 <br /> SIGNED TITLEQW&rot /' J DATE <br /> rI <br /> V*N <br /> H+ I I I I I <br /> DEPARTMENT USE ONLY <br /> Application Accepted By / Date Arealfi Employee ID#A � <br /> Grout Inspection By Ah'SWZ1ZA_/ Date /� ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS Z <br /> PE SC ReceivedChec Amount Date Permit/ Invoice# Well ID# <br /> Codes nfo ash Remitted Service Request# <br /> it <br /> EHD 43-06 8/01/16 WELL/PUMP PERMIT <br />