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f 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 3 7G, e e M e c S­-� ISE CITY/ZIP �C��M P O _ � J�ay m <br /> N �W� �i�iW'-�s6� lOS-�q5 -23 SG <br /> CROSS STREET s` <br /> ,^ C) A�PPAR�C[EJL�SIZEE''s LAND USE APPLICA'n0N)# /� � <br /> OWNER NAME .TCi S r 1 I /1�tI !</ W U /I/ VYQK.V 7 PHONE r�`' — C, <br /> / /h <br /> OWNER ADDRESS 'Jy�'IL D /7R�iJL� �/V CITY/STATE/ZIP ✓6.01 <br /> CONTRACTOR \ l a 11 v l� n q PHONE SC 1 - 2 7/7 cl <br /> CONTRACTOR ADDRESS P.�� �))C 62 CITY/STATE/ZIP (-7a EA S 4% ✓ <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATEIZIP <br /> LICENSE /'C-57 >KC-61 i. D-09 I..I Other NUMBER EXPIRATION DATE <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391)❑Dibrornochloropropane(4392) 1 Arsenic(4393) <br /> INTENDED USE 'K,,Domestic/Private Irrigation/Agricultural G Industrial i7 Water Quality Monitoring I: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 Well Afteration/Modification [-Other <br /> = Monitoring Well(s) #of wells !!Soil Boring(s) #of borings Geotechnical #of bodngs <br /> Out-Of-Service Well Out-Of-Service Well Renewal F Cross-Connection Repair <br /> ew Pum is Pump Replacement i Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method/'kMud Rotary ri Air Rotary i 1 Auger C',Cable Tool ❑Push Point I Other <br /> Proposed Well Depth �73 ft Excavation )�in diameter ❑Open Bottom XGravel Pack/Gravel Size i/e in diameter <br /> ❑Conductor Casing in diameter / Conductor Casin epth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Schad C�SCO 1'q ❑Steel .)K Plastic I 1 Stainless Steel I'Other <br /> Grout Seal Depth 0 C ft i Neat Cement(94 lb bag/5-10 gal water) �A Sand Cement IC 3 sack mixl7 gal water <br /> < Bentonite(20%solids) Cl Other <br /> Grout Placement Method X Pumped !Free Fall a Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By�<'Driller Pump Contractor - Other <br /> Concrete Pedestal CiDimensions:Width A ft Length ft Thick in i;Christy Box i Stove Pipe <br /> PUMP Submersiblel�iTurbine Other HP Pump Set ft Standing Water Level 1G0 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 /> MINIM 48 HOUR ADVANCE NOTICE REQUIRED FO`R'INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED / / L'`�-w � TITLE �r I ` �yr l cArf)t DATE 5 - 1 <br /> e <br /> 5 <br /> N w yq <br /> RP <br /> i AQ <br /> Z<rA T M E N T U E O L Y H DEPARTME T <br /> Application Accepted By Date NV <br /> L�� Area Employee ID# <br /> Grout Inspection By Date , SPECIAL Well Permit <br /> Pump Inspection By Date J_j_T_, I_��, WAIVER Received <br /> Soil Boring Inspection yy Date \� Gti Constructed W I Depth ft l <br /> COMME FS N' A/ I a-4L D <br /> CPE SC Received Check#/ Amount Date Permit' # Well ID# <br /> s Codes I fo B Cash Remitted Service Re uest# <br /> 5 z5- t,U O <br /> A -7 -Z y 3 <br /> a� <br /> EHD 4306 revised 4/14/18 WELL/PUMP PERMIT <br />