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s <br /> ` WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 <br /> r <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YE R FROM DATE ISSUED <br /> ,( <br /> t cn <br /> JOB ADDRESS i 3`� � /`-� CITY/ZIP m <br /> A / D <br /> CROSS STREET 0.../Y�_A /� APN '� PARCEL SIZE �� AND USE APPLICATION# A <br /> OWNER NAME / � ���dl/l f PHONE' �� �� y <br /> OWNER ADDRESS L J�� �+ 1 J CITY/STATE/ZIP j f <br /> CONTRACTOR Aj—X 7,'AcyS'J /►�(iL/4��L PHONE 32 Y- V- LS <br /> CONTRACTOR ADDRESS �O 10 j L2 9 CITY/STATE/ZIP L V V 4 <br /> SUBCONTRACTOR �E�� Lll �I•�.AP`f PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE /<C:-57 ❑C-61 ❑D-09 ❑Other NUMBER .3 EXPIRATION DATE <br /> DOMESTIC WELL SAMPLING:❑General Mineral/Coliform Bacteria (4391)❑Dibromochloropropane (4392)❑Arsenic(4393) <br /> INTENDED USE Domestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization <br /> ❑Public Water System <br /> If different from Owner: Water System Name Uontact Name or Phone Number <br /> TYPE OF WORK >5fqew Well ❑Replacement Well ❑Well Alteration/Modification ❑Other <br /> ❑Monitoring Wells) #of wells ❑Soil Boring(s) #of borings #of borings <br /> ❑Geotechnical <br /> F-1 Out-Cf-Service Well ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> ew Pump ❑Pump Replacement ❑Pump Repair [-]Raise Well Casing <br /> WELL CONSTRUC ION <br /> Drilling Methoq%C�jMud Rotary ❑Air Rotary ❑Auger ❑Cable Tool E]Push Point ❑ Other <br /> Proposed Well Depth ft Excavation in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter <br /> F1 Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched :! 2 ❑Steel lastic E]Stainless Steel ❑Other <br /> 11 <br /> Grout Seal Depth Li ft E]Neat Cement(94 lb bag/5-10 gal water) and Cement sack mix17 gal water <br /> ❑Bentonite(20%solids) ❑Other <br /> Grout Placement Method-*rum ped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By k5riller E]Pump Contractor ❑ Other <br /> ❑Concrete Pedestal Dimensions:Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe <br /> PUMP }CSubmersible❑Turbine ❑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 /> MINIMU 24 UR DVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br /> SIGNED !tom— TITLE lj DATE <br /> / <br /> /h <br /> TIT 7"7— — . --L I J---j <br /> F T <br /> DEPARTMENT USEO <br /> LY <br /> Application Accepted By Date Area Employee ID# <br /> Grout Inspection By '14S Date i'S�i� ❑ ECI L Well Permit <br /> Pump Inspection By hi\-V2O0 Date WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth 3r0 ft <br /> COMMENTS <br /> PE Sc Received heC Amount Permit/ <br /> o fo B ash emitted Date Service Re uest# Invoice# Well ID# <br /> / g _ tc <br /> Li <br /> vz <br /> EHD 43-06 8/01/16 WELL/PUMP PERMIT <br />