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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 / C-6 <br /> G CALL 209 953-7697 FOR INSPECTIONS r'EXPIRES 1/YEAR FROM DATE ISSUED <br /> JOB ADDRESS <br /> 3OJ q � L C- /'♦I VIG CITY/ZIP &C4110h , (� [ m <br /> L1 M /y D <br /> GROSS STREET ]v 'w,, APN 2Zgl- •6-3-IQ PARCEL SIZE!6-g LAND USE APPLICATION#(�/� <br /> CO <br /> OWNER NAME PA �`J GMS ��r �,p PHONE 96 -��(Jy <br /> J OWNER ADDRESS 6✓ ' . v CITY/STATE/ZIP�E�/ap� / l a <br /> CONTRACTOR Migellr,l f PHONE 52z- 12-3 <br /> CONTRACTOR ADDRESS I Icj Ib'Crs CITY/STATE/ZIP 6�(JI i (_a ?535-7 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS �CIITY//STTAT`E7/ZZIIP �f <br /> LICENSE �C-57 C-61 I D-09 Other NUMBER Y/�VV� 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 I I Soil Sampling/Characterization <br /> ❑ Public Water System <br /> If different from Owner. Water Systern Name Contact Name or Phone Number <br /> TYPE OF WORK ❑ New Well Weplacement Well U Well Alteration/Modification 1.1 Other <br /> ❑ Monitoring Well(s) #of wells I I Soil Boring(s) #of borings Geotechnical #of borings <br /> Out-Of-Service Well I 1 Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> C New Pump I Pump Replacement !i Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling MethodxMud Rotary I 1 Air Rotary 11 Auger Cable Tool ❑ Push Point 1 I Other <br /> Proposed Well Depth 3So ft Excavation 2-0 in diameter I-I Open Bottom Nravel Pack/Gravel Size in diameter <br /> 1! Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter 10 In Thickness/Gauge/ASTM Sched 2-cx=> 1! Steel lastic 1 Stainless a teel n Other <br /> Grout Seal Depth ft I Neat Cement(94 Ib bag/5-f0 gal water) 3Sand Cement 1"a/ sack mix/7 gal water <br /> I I Bentonite(20%solids) Ll Other <br /> Grout Placement Method I I Pumped ❑ Free Fall Other I I Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller I I Pump Contractor t_I Other <br /> n Concrete Pedestal I'Dimensions:Width ft Length ft Thick in Christy Box I Stove Pipe <br /> PUMP I I Submersible❑ Turbine 1 I 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 /> MI UM 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697Q <br /> SIGNED TITLE Pi /ICY r DATE <br /> Ub <br /> E Q <br /> N N <br /> R <br /> LGZ QVrPi EPARTMENT USE ONLY <br /> r <br /> Application Accepted By Date Area Employee ID# <br /> ALI <br /> Grout Inspection By / aS4 rte+ � Date & 1 l �T SPECIAL Well Permit <br /> Pump Inspection By Date <br /> WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC ReceivedCb ck#/ Amount Date Permit/ Invoice# Well ID# <br /> odes Info Cash Eenrlitted Service Request# <br /> EHD 43-06 8/01/16 WELL/PUMP PERMIT <br />