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WELL/PUMP PERMIT <br /> SAN JOXQUIN 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 'I YEAR FROM DATE ISSUED <br /> a /- <br /> JOB ADDRESS Maki fi 01 I� ye4 CITY/ZIP /J�_G(r1 C�Q f (fA 1 5-r A, m <br /> CROSS STREET�,S"I t/"ox4w&rA ( 'e_ APN 2 2OUDbO 9 PARCEL SIZE/' I�LAND USE APPLICATION# 0 <br /> OWNER NAME jhc :3[-f� P PHONE ur <br /> OWNER ADDRESS 1'� PO CITY/STATE/ZIP Q [� <br /> CONTRACTOR K lP l n GIc�P^� 1 - -J PHONE <br /> /�d <br /> CONTRACTOR ADDRESS ,IL'C.L/J� 'nftIGII A,mgj/`4 Poeid �Lfde IaD CITY/STATE/ZIP Sfcch4no �Cy.A (���`���� <br /> SUBCONTRACTOR V i W k/iA��'/fig .L/v(� }� PHONE Cpw_`) L&/-�1 - / U <br /> SUBCONTRACTOR ADDRESS ) 0lL,i- ✓�'�e !CITY/STAA{TE/ZIIP lye .lr �r� /'^ <br /> LICENSE �C-57 ❑ C-61 ❑ D-09 ❑ Other NUMBER T� lc) / EXPIRATIONDATE 'L/?Q/ Gy2O <br /> DOMESTIC WELL SAMPLING: h General Mineral/Coliform Bacteria (4391) ❑ Dibromochloropropane(4392) 5 Arsenic(4393) <br /> INTENDED USE ❑ Domestic/Private n Irrigation/Agricultural n Industrial ❑ Water Quality Monitoring F-r'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 0/Soil Boring(s)3 #of borings ❑ Geotechnical #of borings <br /> ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> [I New Pump ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION � r <br /> Drilling Method L] Mud Rotary ❑ Air Rotary [I/'Auger 11 Cable Tool ❑ Push Point ❑ Other to <br /> Proposed Well Depth 440 ft Excavation in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel Size In dia <br /> ❑ Conductor Casing in diameter / Conductor Casing Depth ft s 3 <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑ Steel ❑ Plastic ❑ Stainless Steel p 01 <br /> Grout Seal Depth ft VNeat Cement(94 Ib bag/5-10 gal water) ❑ Sand Cement ter <br /> ❑ Bentonite(20%solids) ❑ Other <br /> N� <br /> Grout Placement Method IM/Pumped ❑ Free Fall Othe ❑ Retardant/Accelerator(name) ENT <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 /> NIMUM 48 HOUR ADVANCE NOTICE REQUIRED FOL INSPECTIONS - PLEASE CALL (209) 953-7697 <br /> SIGNED TITLE FOL <br /> 1wt 6�0 -1 DATE <br /> m' { u <br /> ` \N7.. , <br /> fir. <br /> EPA RTMENT U E O N L Y <br /> Application Accepted By Date L2P Area ployee ID# <br /> Grout Inspection By Date ❑ t SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection By Date 1 -710 Constructed Well Depth ft <br /> COMMENTS '� J <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B Pash ARe ifted Service Re uest# <br /> EHD43-06 revised 4/14/18g�3"���(/� WELL/PUMP PERMIT <br />