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WELL/PUMP PERMIT <br /> r SAN JC-QUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 <br /> NON-REFUNDABLE PERMIT \- ' C CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS V v o,f J�t R n Z � Q`>CITYP L cI ) C A I 2,12 <br /> m <br /> 1 <br /> 1 <br /> CROSS STREET k� D-t� I T APN�/' r �- -�%� PARCEL SIZE I G LAND USE APPLICATION <br /> OWNER NAME c/a 4C_,r `fy,1> \ «Y)Z41.0441 / �PHONE C�1 4� -S(/) <br /> (/)7 <br /> OWNER ADDRESS (]V Jl�/iV�W C\G>/ CITY/STATEZP 'T� <br /> CONTRACTOR V '�1\1 y l��J//( 1y�1 1 fl <br /> O F, �I PHONE`1 J C)- � /7 79 <br /> CONTRACTOR ADDRESS `1// 3 CITY/STATE/ZIP r <br /> P �CI 1 t ( A C1 5 GJZ <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE//ZIP <br /> LICENSE C-57 C-61 L D-09 .I Other NUMBER—2LI>us EXPIRATION DATE '7-3 <br /> J <br /> DOMESTIC WELL SAMPLING:I I General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392)LI Arsenic(4393) <br /> INTENDED USE Domestic/Private _.Irrigation/Agricultural i Industrial I Water Quality Monitoring I-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 D Well Alteration/Modification :7 Other <br /> Monitoring Well(s) #of wells ❑Soil Boring(s) #of borings Geotechnical •of borings <br /> Out-Of-Service Well ❑Out-Of-Service Well Renewal G Cross-Connection Repair <br /> New Pump ❑Pump Replacement [_Pump Repair C Raise Well Casing <br /> WELL CONSTRUCTION ) <br /> Drilling MethodMud Rotary [I Air Rotary .Auger Cable Tool Push Point Other <br /> Proposed Well /Depth J71; ft Excavation _in diameter a Open Bottom 7( Gravel Pack/Gravel Size I�LJ- in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_�_in Thickness/Gauge/ASTM Sched w 0 Steel XPlaslic Stainless Steel Other <br /> Grout Seal Depth )(v ft - Neat Cement(94/b bag.15-10 gal water) Sand Cement �LS sack mixr7 gal water <br /> Bentonite(20%solids) :- Other <br /> Grout Placement Method Pumped Free Fall -:Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By ,Driller Pump Contractors- Other <br /> Concrete Pedestal I_Dimensions:Width D ft Length 7ft Thick in Christy Box Stove Pipe <br /> PUMP Submersibles 1 Turbine Other HP J Pump Set ' -3 ft Standing Water Level <br /> I HEREBY CERTIFY THAT 1 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 /> MINIM 8 HOU DVANCE NOTICE REQUIRED FOR INSPECTIONSPEASE CALL(209)953-7697 <br /> SIGNED /-� TITLE I(� I^rJ" 1 DATE 5 /`, 7 / <br /> I <br /> is <br /> NT <br /> ED <br /> 20% <br /> COUNTY <br /> NIAE <br /> TMENT <br /> EI\ RTMENT U E O <br /> Application Accepted B Date / / Area-6x'4/ Employee ID# <br /> Grout Inspection By Date TT SPECIAL W@II Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Inspection By UN Date Constructed Well Depth <br /> COMMENTS 7 \ 5 7'Q \ \1ix <br /> PE SC Received Check#/ Amount Date PermrU Invoice# Well ION <br /> Codesfo B Cash Remitted Service Re uest# <br /> n l <br /> L — '<2 C <br /> E ED 43-06 revised 4/14/18 WELL/PUMP PERMIT <br />