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• R WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 <br /> NON-REFUNDABLE PERMIT f CALL(209)/953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE(ISSUED <br /> JOB ADDRESS 1 <br /> CITY/ZP j14 fIaA/ I/' <br /> CROSSSTREET APN Nyi „ ✓ PARCELSI4LAND USEAPPLICATION# <br /> yA <br /> OWNER NAME (j( -- PHONE two, <br /> OWNER ADDRESS CITY/STATE/ZIP `•A� '7 <br /> CONTRACTOR r 1y `� PHONE q qIr—IJ <br /> CONTRACTOR ADDRESS 0 //11 Y r y !tel-NO CITY/STATEZP S �[ / <br /> SUBCONTRACTOR V 4xT... <br /> _Y 1`0 <br /> SUBCONTRACTOR ADDRESS—7,j 8( Il C Av -Y .)� CITY/STATEZP O3 <br /> LICENSE j C-57 ❑C-61 ❑D-09 ❑Other NUMBER U3-0-9,S E O <br /> DOMESTIC WELLSAMPUNG:D General Mineral/Coliform Bacteria(4391)D Dibromochloropropane(4/2)0 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 Contact Name or Phone Number <br /> TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification /IR.Ise <br /> r <br /> ❑Monitoring Well(s) #of wells ❑Soil Boring(s) #or�Geotechnical #of borings <br /> ❑Out-Of-Service Well ❑Out-Of-Service Well Renewals-Connection Repair <br /> ❑New Pum ❑Pum Replacement ❑Pum Repair Well Casin <br /> WELL CONSTRUCTION <br /> Drilling Method !p Mud Rotary ❑Air Rotary /Auger ❑Cable Tool ❑Push P int ❑ Other <br /> Proposed Well Depth 519 Excavation in diameter ❑ pen Bottom ❑Gravel Pack/Gravel Size in diameter <br /> ❑Conductor Casing in diameter / Conductor Casing D pth ft <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Sched ❑Steel ❑Plastic ❑ nless Steel D Other <br /> Grout Seal Depth ft j Neat Cement(94 Ib bag/5-10 gal ter) ❑Sand Cemen sack mixf7 gal water <br /> ❑Bentonite(20%solids) 11 Other <br /> Grout Placement Method Pumped ❑Free Fall ❑Other ❑Retardant/A t ame) <br /> PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑ qfher <br /> Concrete Pedestal DDimensions:Width ft )Length ft T ' in ❑Christy Box ❑Stove Pipe <br /> PUMP ❑SubmersibleD Turbine ❑Other P PU*S&J ft Standing Water Level ft <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLIC ION AND THAT E ORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RUL AND REGULATIIS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRA ORS STATE LI N BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> I U 48 U VANCE NOTICE EQUIRED IF 1 CTIONS-PLEASE CALL(209) 53-7697 <br /> SIGNED 1 �/, ne— DATE ' <br /> T <br /> P A TME N;XEN L Y <br /> Application epted By Date Area Employee ID#� <br /> Grout spection Byl� Date IF ❑ SPECIAL ell Permit <br /> Pu Inspection By Date ❑ WAIVER Received <br /> Soil Bo ng Inspection By Date Constructed Well Depth ft <br /> COMMS S <br /> Pe SC Received Check#/ Amount Date Permtt/ Invoice# Well ID# <br /> Codes Info B C sh Remitted Service Re uest# <br /> Twin <br /> 3 <br /> EHD 43-06 reNsed 4/14/18 WELL/PUMP PERMIT <br />