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t <br /> 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 T rP��JVW ^� ���yp,.-�, ,,.�,�yr^ CITY/ZIP f �'" m <br /> CROSS STREET�� 1�` 1�-"I's✓APN Z`V I—✓6 /v�`�-�PARCEL SIZE lot GgLAND USE APPLLIC`TION# p <br /> OWNER NAME CFT NJ DEv /L Pm�-F LIC. PHONEE(C.M S 2--VAS Z(p <br /> OWNERADDRESS i6bS�((��LjAr^i�J%)LLT(��tc`cf��1 E{/.�yfCy�(eJLLAE CAn\Y(STATE21P Qu—,, JQr��fC.r'1✓(�`u^ '`]fL�I�7O <br /> CONTRACTOR MCCCE 1 Wj&)I'yv ''(`S5c) ^`- �j� IN)(—. ��P-r�HONE l L, x)ZI6F 0 Z' <br /> CONTRACTOR ADDRESS 272. R�b ��h T CITY/STATEZP l "ESN)O d C 1 l /3—I <br /> SUBCONTRACTOR r" PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP 21 <br /> / {� <br /> LICENSE -57 7 C-61 r D-09 ❑Other NUMBER 50(01� EXPIRATION DATE �+ Z <br /> DOMESTIC WELL SAMPLING:I General Mineral/Coliform Bacteria(4391)F1 Dibromochloropropane(4392)r Arsenic(4393) <br /> INTENDED USE I I Domestic/Private J Irrigation/Agricultural r Industrial O Water Quality Monitoring Soil Sampling/Characterization <br /> I I Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK O New Well ❑Replacement Well Cl Well Alteration/Modification -1 Other <br /> C1 MonitoringWell(s) #of wells OSoil Boring(s) #of borings XGeotechnical ca ofborings <br /> O Out-Of-Service Well O Out-Of-Service Well Renewal J Cross-Connection Repair <br /> n New Pump r Pump Replacement n Pump Repair n Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method n Mud Rotary_n Air RotaryAuger r Cable Tool r Push Point n Other <br /> Proposed Well Depths tSC)ft Excavation 7 in diameter i- Open Bottom a Gravel Pack/Gravel Size in diameter <br /> O Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched �Steel O Plastic a Stainless Steel C Other <br /> Grout Seal Depth --'—� ft pleat Cement(94 Ib bag/5-10 gal water) :I Sand Cement sack mix/7 gal water <br /> CI Bentonite(20%solids) C Other <br /> Grout Placement Method .]Pumped XFree Fall Other r Mi r Retardant/Accelerator(name) <br /> PEDESTAL Installed By i i Driller i i Pump Contractor i i Other <br /> L Concrete Pedestal ODimensions:Width ft Length ft Thick in C Christy Box ❑Stove Pipe <br /> PUMP n Submersiblen Turbine r 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 ALIFO NIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMP ON LAWS <br /> MINIM HOU V C OTICE REQUIRED FOR <br /> INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED TITLE D1 V 'r tJy DATE 2—�0 <br /> R :4 rMF <br /> CF�V�T <br /> qM,q 20 O <br /> ti R Q�iN 1y <br /> O pq� q4 Nn. <br /> Np <br /> EPA TMENT- 'USE <br /> �ONLY py/►n(,'��/y�./, <br /> Application Accepted By ( Date 1 I /] Area`�T Employee <br /> Grout Inspection By Date TTII h SPECIAL W@II Permit <br /> Pump Inspection By Date LI WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE Sc Received ChecW Amount Date Permit/ Invoice# Well ID# <br /> Codes Info Remitted Service Re uest# <br /> EHD 43-06 revised 4/14/18 ����77l/�0 �_—Y/•"I• ���!��'•y -.11/PUMP PERMIT <br />