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1 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 /> JOB ADDRESS 12-7 PAC-IG/G.. iZcA 0 CITY/ZIP M4N��Cf( , 95337 m <br /> / D <br /> CROSS STREET W U 4 'IWC anrTE A V 01J U-= APN 211'z ay vo-- PARCEL SIZE �� LAND USE APPLICATION# 0 <br /> OWNER NAME ZfA-SAN W EQQ J e V-)Ob Pro <br /> ; , r h e-5 PHONE 20 5 - S 13—) <br /> /3/s /^ Gf <br /> OWNER ADDRESS Ct 1�r <br /> WCfs yuse0-1iTE ✓ v U� CCITY/STATE/ZIP M14t rC4A, CAUF0R.v A 51•r•7-r-7 <br /> CONTRACTOR PHONE / <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP "iX7-SdSeA "F' <br /> SUBCONTRACTOR APVA,J(eP (%60 CKPL tA-re,,.,/ %,mac p3A CIO. n/EV (*Ep Cx PLo,(A7.c, .j PHONE 4iG-7-79 -00S,; <br /> SUBCONTRACTOR ADDRESS 10'79 5v„/?2/SE 4t E ITE 8-339 CITY/STATE/ZIP R0SCV'L/-e, (A, 56-661 <br /> LICENSE )<C-57 ❑ C-61 ❑ D-09 ❑ Other NUMBER /off/ Yi% EXPIRATION DATE r/?//T. -L— <br /> DOMESTIC WELL SAMPLING: ❑General Mineral/Coliform Bacteria (4391) ❑ Dibromochloropropane(4392)❑ Arsenic(4393) <br /> INTENDED USE ❑ Dome'stic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring >9: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 <br /> ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings 'Geotechnical 1 #of borings <br /> ❑ 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 Rotary ❑ Air Rotary Auger ❑ Cable Tool ❑ Push Point ❑ Other <br /> Proposed Well Depth $v ft Excavation t/—6 in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel Size in diameter <br /> ❑ Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑ Steel ❑ Plastic ❑ Stainless Steel ❑ Other <br /> Grout Seal Depth .S^0 ft .Neat Cement(94 Ib bag/5-10 gal water) ❑ Sand Cement sack mix17 gal water <br /> ❑ Bentonite(20%solids) ❑ Other <br /> Grout Placement Method ❑ Pumped ❑ Free Fall 0 Other 7A-E1'4'L- ❑ 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 ❑ Submersible[] 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 COMPENSATION LAWS. <br /> MINIMUM HOUR AE NOTICE REQUIRED FOR INSPECTIONS -PLEASE CALL (209) 953-7697 <br /> SIGNEDTITLE &G1416fiX DATE 9j19r/`6 <br /> a <br /> 9 <br /> o Q at <br /> A� <br /> E p RT <br /> 9 <br /> DEP TMENT U E NLY <br /> Application Accepted By Date � Area mployee ID# <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection By ,,4 Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#/ Amount Permit/ <br /> Codes Info B Cash emitted Date Service Request# Invoice# Well ID# <br /> 50 20 '7 9 -2- <br /> END 43-06 8/01/16 WELL/PUMP PERMIT <br />