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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 C 1_ 2{09 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> Ln <br /> JOB ADDRESS �� ��►� J r CITY/ZIP 7 0 m <br /> �, D <br /> CROSS STREET [! <br /> aL moi k APN PARCEL SIZE LAND USE APPLICATION#y '7 <br /> OWNER NAME PHONE �V. Z ( / <br /> OWNER ADDRESS y��1' CITY/STATE/ZIP C �7 ^� <br /> CONTRACTOR r IW/"" ��GG / PHONE�cy3y �� [ / Z/ " <br /> CONTRACTOR ADDRESS ` CITY/STATE/ZIP`/���✓N/�� �� <br /> SUBCONTRACTOR PHONE J 7, <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE X <br /> C-57 IJ C-61 11 D-09 Ll Other NUMBER .> ✓ EXPIRATION DATE 6'-1 <br /> DOMESTIC WELL SAMPLING: 1 General Mineral/Coliform Bacteria (4391) Dibromochloropropane(4392) i Arsenic(4393) <br /> INTENDED USE Ulf Domestic/Private I I Irrigation/Agricultural ❑ Industrial ❑ 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 S-New Well I I Replacement Well l] Well Alteration/Modification ❑ Other <br /> ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings ❑ Geotechnical #of borings <br /> ��I+O� ut-Of-Service Well 11 Out-Of-Service Well Renewal F-1Cross-ConnectionRepair <br /> �'2` 1eW Pump n Pump Replacement I I Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Methodw:4 `Mud Rotary ❑ Air Rotary L I Auger U Cable Tool ❑ Push Point J Other <br /> Proposed Well Depth�ft Excavation I")— - in diameter LI-Open Bottom KGravel Pack/Gravel Size in diameter <br /> ❑ Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched L 0 I-I Steel 4<Plastic I1 Stainless Steel ❑ Other <br /> Grout Seal Depth ft ❑ Neat Cement(94 lb bag/5-10 gal water) _*zand Cement sack mix/7 gal water <br /> L Bento e(20%solids) ❑ Other <br /> Grout Placement MethoW Pumped LI Free Fall ❑ Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By fit'Driller Ll Pump Contractor Cl Other <br /> ❑ Concrete'¢e7destal (]Dimensions:Width ft Length ft Thick in ❑ Christy Box a Stove Pipe <br /> PUMP ubmersible❑ Turbine 11 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 LAWS. <br /> MINIMUP424 HOU ADVANCE NOTICE REQUIRED FOR// INSPECTIONS - PLEASE CALL (209) 9533--7697 <br /> SIGNED i(it ./ TITLE iD W DATE G l� <br /> 1 <br /> ni <br /> ENVjl U TY <br /> T D P T <br /> NIT <br /> I 117 <br /> EP RTMENT USE ONLY IL <br /> Application Accepted By Date O Area '( Employee ID# <br /> Grout Inspection By EC24 Date �g 1'_ LI SPECIAL Well Permit <br /> Pump Inspection By Ay'rM\1 Date lq-1 3 111 IJ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Amount Date Permit/ Invoice# Well ID# <br /> odes 110 B Cash Remitted Service Request# <br /> WIN, �:Ii5 <br /> EHD 43-06 8/01/16 WELL/PUMP PERMIT <br />