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WELL/PUMP PERMIT <br /> ff <br /> SAf!JOAQU:N COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 <br /> NON-R:-FUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOAPDRESS /V CITY/ZIP 4 QJ4-11 m <br /> m <br /> CROSSSTREET Lor /ZO APNZ:2- PARCEL SIZE LAND USE APPLICA ION# rn <br /> v <br /> n p' /1 / rn <br /> OWNER NAME l l 1 V re' / 1w Es <br /> Zy C1 6.7Q-7 -9 Sty-7 cn <br /> (OWNER ADDRESS / C/9 ` ✓ V G� �p /� N> ��- CITY/STATE/ZIP Es C- 10 C /4 gsg 2— <br /> CONTRACTOR W S C©�s-� �y,p r�(1 L O►1 y,.L� C_ PHONE Z0_1 - 119)S—-)SL I <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE -57 ❑C-61 L]D-09 El Other NUMBER G�����L^' EXPIRATION DATE 3 1Z <br /> DOMESTIC WELL SAMPLING:EgGeneral Mineral/Coliform Bacteria (4391)❑Dibromochloropropane(4392)❑Arsenic(4393) <br /> INTENDED USE omestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization <br /> ❑Public Water System <br /> If different from Owner: Water bystem Name Uontact Name or Phone Number <br /> TYPE OF WORK ew Well ❑Replacement Well ❑Well Alteration/Modification ❑Other <br /> # <br /> El Monitoring Well(s) #of wells E]Soil Boring #of borings s) ❑Geotechnical 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 ud Rotary E]Air Rotary ❑AugerCable Tool E]Push Point ❑ Other <br /> Proposed Well Depth Z1 o ft Excavation I All in diameter E]Open Bottom Neravel Pack/Gravel Size - in diameter <br /> ❑Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter� in Thickness/Gauge/ASTM Sched 2-00 [:]Steelastic El Stainless Steel ❑Other <br /> Grout Seal De h 0 O ft ❑Neat Cement(94 Ib bag/5-10 gal water) and Cement �.� sack mix/7 gal water <br /> ❑ ntonite(20° olids) ❑Other <br /> hod umpe <br /> Grout Placement Metd ❑Free Fall ❑Other ❑Retardant/Accelerator(rr1ame) <br /> PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑ Other <br /> ❑Concrete Pedestal dimensions:Width ft Length ft Thick in [:]ChristyBox ❑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 L S. <br /> MINIMU OU ADVA E N TICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br /> SIGNED TITLEnDATE L <br /> v <br /> i t f H <br /> 4. <br /> S lLl - <br /> E <br /> J <br /> DE ARTMENT SE ONLY ZIAL <br /> Application Accepted By nate I i _ . FlnnioveeGrout Inspection By �'3 ��`� �t� Date WL-11 Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMM NTS S 1 <br /> v <br /> o <br /> PE Sc Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Ifo By Cash Remitted Service Reque t# <br /> G �-t 3R ` tA)P <br /> EHD 43-06 8/01/16 WELL/PUMP PERMIT <br />