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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 l�EXPIRES 1 YEAR FROM DATE ISSUED <br /> to <br /> JOB ADDRESS 3 A <br /> �G e - e I'\e`'S CITY/ZIP CCNM Q O <br /> N Nw� ggW4! s6��4S+A5 -y23 So�' <br /> CROSS STREET ,^ �.y ,F/{� /��'/ PARCEL 512E• LAND USE APPLICATION*# i a <br /> OWNER NAME ,-TG S t"1 rot nry�/� /,�t1 /K/��W U A� 6PjZ o s / PHONE �r'`�/�- <br /> OWNER ADDRESS ,�11LwDp X�(J�L UV CITYISTATEZP ✓6DI <br /> CONTRACTOR 1 Q T Y '� n q PHONE�(Q <br /> CONTRACTOR ADDRESS �� r)X �2 CITY/STATE/ZIP C-jo� \A S 4% ✓ <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/ST1ATE/ZJP <br /> LICENSE 'X C-57 XC-61 D D-09 L.Other NUMBER 1 9 EXPIRATION DATE 7-7 1 1_I <br /> DOMESTIC WELL SAMPLING:❑General Mineral/Coliform Bacteria(4391)F.Dibromochloropropane(4392)L Arsenic(4393) <br /> [LN-NDEDUSE A Domestic(Private Irrigation/Agricultural C7 Industrial G Water Quality Monitoring I 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 New Well ;I Replacement Well 'I Well Afteration/Modification 1-i Other <br /> L'Monitoring Well(s) #of wells a Soil Boring(s) 4 of borings i Geotechnical s of borings <br /> C Out-Of-Service Well L Out-Of-Service Well Renewal F]Cross-Connection Repair <br /> ew Pump LI Pump Replacement '_i Pump Repair E Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method/*AMud Rotary ❑Air Rotary ❑Auger ❑Cable Tool I Push Point I Other <br /> Proposed Well Depth �75 ft Excavation)—in diameter I Open Bottom 'y(Gravel Pack/Gravel Size 1/.d _ in diameter <br /> Conductor Casing in diameter / Conductor Casineepth / ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched C)DC( (q F:Steel .A Plastic , Stainless Steel ❑Other <br /> Grout Seal Depth 0 C It Neat Cement(94/b bag/5-10 gal water) Sand Cement I C 3 sack mixn gal water <br /> n Bentonite(20%solids) C Other <br /> Grout Placement Method X Pumped C:Free Fall Other 2 Retardant/Accelerator(name) <br /> PEDESTAL Installed By X,Driller -1 Pump Contractor G Other <br /> A,Concrete Pedestal:i Dimensions:Width A It Lengthft Thick n ❑Christy Box _i Stove Pipe <br /> PUMP Submersible[--Turbine G Other HP Pump Set ft Standing Water Level 1C C� 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 M 48 HOUR ADVANCE NOTICE REQUIRED FOR <br /> 'INSPECTIONS <br /> --PLEASE CALL(209)953-7697` <br /> SIGNED w-wA TITLE v`t ` �Jl U t DATE <br /> VI <br /> e <br /> 5 <br /> RP <br /> FAT ITIL; 1, <br /> —]#F-1-1-1-1 <br /> I <br /> P,A TMENT U E O LY ENVIR <br /> �jJ-p'LTH DEPART'M,-EF <br /> Application Accepted By Date+c7jC� Area-� ' Employee ID# <br /> Grout Inspection By Date C SPECIAL Well Permit <br /> Pump Inspection By' Date t I 1 _ r a n,rt ] WAIVER Received _ �y <br /> Soil Boring Inspection y Date Constructed W / <br /> I Depth It <br /> COMME S L CAah <br /> L 10 Pa r ti, <br /> ��✓ PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> s Codes I fo B Cash Remitted Service Re uest# <br /> V-1 4y-zs' VJo , - <br /> -Zy- 3 <br /> a� <br /> EHD 43-06 revised 4/14/18 WELL/PUMP PERMIT <br />