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I <br /> WELL/PUMP PERMIT P '� <br /> SAN,.!OAQUIN.OUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 <br /> NON-REFUNDABLE PERMITCALL 209 953-7697 FOR INSPECTIONS EXPI ES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS CITY/ A�-41'e rS � � m1e D <br /> ROSS STREETV p <br /> �' J O APN ARCEL SIZE LAND USE APPLICATION# <br /> OWNER NAME G� .{/ . 0 Q ✓1 �1 P,H/ONE 610 2 �J� o? <br /> OWNER ADDRESS Il CITY/STATE/ZIP Afo I-C, C , 9533 E <br /> CONTRACTOR "// PHONE_7 GS— G v 2 " <br /> CONTRACTOR ADDRESS <br /> _ CITY/STATE/ZIP <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP r <br /> LICENSE *'ORG-57 ❑ C-61 ❑ D-09 I I Other NUMBER 5 7 y21 F EXPIRATION DATE <br /> DOMESTIC WELL SAMPLING:AGeneral Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) i Arsenic(4393) <br /> INTENDED USE I916omestic/Private 11 Irrigation/Agricultural a Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization <br /> ❑ Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK or"Qew Well ❑ Replacement Well ❑ Well Alteration/Modification FJ Other <br /> 1.1 Monitoring Well(s) #of wells [1 Soil Boring(s) #of borings I I Geotechnical #of borings <br /> ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> ❑ New Pump LI Pump Replacement [I Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method mud Rotary ❑ Air Rotary CI Auger 11 Cable Tool ❑ Push Point ❑ Other/ <br /> Proposed Well Depth z Y0 ft Excavation /Jr in diameter F1 Open Bottom EYGravel Pack/Gravel Size_ in diameter <br /> ❑ Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter p in Thickness/Gauge/ASTM Sched Jjd#e 1 1 11 Steel Mastic El Stainless Steel ❑ Other <br /> Grout Seal Depth2g>C> ft l I Neat Cement(94 Ib bag/5-10 gat water) ❑ Sand Cement sack mix/7 gal water <br /> "entonite(20%solids) I I Other <br /> Grout Placement Method limped 11 Free Fall f1 Other LI Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller ump Contractor 11 Other <br /> ❑ Concrete Pedestal Ll Dimensions:Width ft Length ft Thick in U Christy Box 1 Stove Pipe <br /> PUMP 1,nubmersible11 Turbine II 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 /> WORKERI COMPENSATION LAWS. <br /> INI 4 UR ADVANCE NOTICE REQUIRED FOR <br /> �III�NSPECTION, - PL SE CALL (209) 953-766997 <br /> SIGNED TITLE(,.i(1C-m"e, �S' DATE S � . -�� <br /> C <br /> CLI 11 <br /> F�krm N,1 <br /> IVEIDI <br /> E IR P: Till <br /> HE LH EA TM N <br /> EE: n R T of ` N v P: L Y / <br /> Application Accepted By Date Area l Employee ID#1Aq <br /> Grout Inspection By / St Date S ❑ SPECIAL Well Permit <br /> Pump Inspection By Date J WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS tj+ }f�j If 6 r S M. <br /> PE SC Received Chec Amount Date Permit/ Invoice# Well ID# <br /> Codes- Info By ash Remitted Service Request# <br /> EHD 43-06 8/01/16 WELL/PUMP PERMIT <br />