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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 EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS n 4^--e— L e—r CITY/ZIP 1 SCCA 1 I 6 n c ��i_D _ m <br /> ` ^ )q D <br /> CROSS STREET / Q 4 1 S-P APN LLQ S 66=6 J Iy PARCEL SIZE rV-60 LAND USE APPLICATION# <br /> OWNER NAME ^I IM Lk3�IV PHONE e�LI <br /> OWNER ADDRESS i CU rT-4J U F� _ CITY/STATE/ZIP S (cf <br /> CONTRACTOR �`�u �t I j DC lit 4�%J� , h I - PHONE 5 71 <br /> CONTRACTOR ADDRESS I 1 �C1 9_,' CITY/STATE/ZIP A// ;! 1'r-sl t' <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE C-57 I I C-61 I I D-09 I I Other NUMBER K2K, _2_ EXPIRATION DATE T -SCiT C <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE Ij Domestic/Private''Irrigation/Agricultural I I Industrial I_I Water Quality Monitoring I I Soil Sampling/Characterization <br /> LI Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK yNew Well L1 Replacement Well i I Well Alteration/Modification D Other <br /> ❑ Monitoring Well(s) #of wells I I Soil Boring(s) #of borings I Geotechnical #of borings <br /> D Out-Of-Service Well ri Out-Of-Service Well Renewal D Cross-Connection Repair <br /> D New Pump I I Pump Replacement I I Pump Repair D Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Methoddl Mud Rotary 11 Air Rotary I 1 Auger Cable Tool f_I Push Point I I Other <br /> Proposed Well Depth�ft Excavation l in diameter 1 1 Open Bottom Gravel Pack/Gravel Size :� in diameter <br /> Ll Conduct Casing in diameter ! Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched 2el4) Steel Plastic Stainless Steel Other <br /> Grout Seal Depth S O ft 11 Neat Cement(94 Ib bag/5-10 ga/water) Sand Cement sack mix/7 gal water <br /> 'Bentonite(20%solids) ❑ Other <br /> [ <br /> Grout Placement Method Pumped 11 Free Fall I I Other 1 1 Retardant/Accelerator(name) <br /> PEDESTAL Installed By I i Driller Pump Contractor I Other <br /> I.'. Concrete Pedestal ':Dimensions:Width ft Length ft Thick in I Christy Box Stove Pipe <br /> PUMP I I Submersible,I Turbine !1 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 /> MINIIV Jill 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 9/53-7/697 <br /> SIGNED ��r.�� TITLE >> I I'� DATE <br /> SII <br /> v <br /> sib' <br /> 5 _ <br /> 1 <br /> C. • ', �P D PA TMENT lJ /E N L Y <br /> Application Accepted By Date 00 Area Employee ID# <br /> Grout Inspection By / ' Date 5! /S SPECIAL Well Permit <br /> Pump Inspection By Date I WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received a Amount Permit/ <br /> Codes Info B ash emitted Date Service Request# Invoice# Well ID# <br /> 2- <br /> EHD 43-06 8/01/16 WELL/PUMP PERMIT <br />