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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 �l.' I CITY/ZIP —�t ` ^. m <br /> CROSS STREET APLN I 1 ` l/ 1�/ I �ARCEL SIZE LAND USE APPLICATION# A <br /> OWNER NAME G1 I� L 1 , /PHONE <br /> OWNER ADDRESS 1 �\ 1 N 4 \ �.�I n t— CITY/STATE/ZIP IC�LV CP <br /> CONTRACTOR (f l �. 1 11 /� l i� PHONE ,/ � <ILtllj� t�I IJ <br /> CONTRACTOR ADDRESS I ( �I �4 CITY/STATE/ZIP <br /> SUBCONTRACTOR t / PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE C-57 11 C-61 I I D-09 Other NUMBER JoLHEW EXPIRATION DATE ' C - C <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) 17 Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE Domestic/Private I I Irrigation/Agricultural I I Industrial ❑ Water Quality Monitoring I l Soil Sampling/Characterization <br /> ❑ Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORKb{New Well I l Replacement Well Li Well Alteration/Modification Li Other <br /> //❑Monitoring Well(s) #of wells 11Soil Boring(s) #of borings 11 Geotechnical f ° <br /> ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair �'��® <br /> ❑ New Pump Cl Pump Replacement n Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION O <br /> Drilling Method K!Vlud Rotary ❑ Air Rotary 11 Auger I I Cable Tool I Push Point ii <br /> J Other &AN p._'AWU201J <br /> Proposed Well Depth �t1 ft Excavation in diameter 11 Open Bottom I I Gravel Pack/Grp /N COUlp ameter <br /> 11 Conducto Casing in diameter / Conductor Casing Depth ft TH�EPge1T FNT <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched Il Steel XPlastic Stainless Steel Other <br /> Grout Seal Depthft ❑ Neat Cement(94 Ib bag/5-10 gal water) Sand Cement sack mix/7 gal water <br /> Bentonite(20%solids) ❑ Other <br /> Grout Placement Method Pumped ❑ Free Fall Other I I Retardant/Accelerator(name) <br /> PEDESTAL Installed By I i Driller [' Pump Contractor ❑ Other <br /> ❑ Concrete Pedestal I I Dimensions:Width ft Length ft Thick in I i Christy Box i Stove Pipe <br /> PUMP [I Submersible I Turbine I I 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 COMP SATION LAWS. <br /> MINI M R A E NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697/- <br /> SIGNED TITLE <br /> l J� —l.� DATE <br /> i <br /> EPAt? TMENT U,6 E ": LY <br /> Application Accepted By'44 Date Area Employee ID <br /> Grout Inspection By /+��(�l/N (/I(�/ � Date �I l't1� I'� ❑ SPECIAL Well Permit <br /> Pump Inspection By Dale ❑ WAIVER Received <br /> Soil Boring Inspectio By Date Constructed Well/Depth 7 � ft <br /> COMMENTS����f j l �: l i t t �7 �—�. _'. r«t L�T Zai <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes fo ash emitted Service Re uest# <br /> SD>v 1 q D <br /> 0 01-A <br /> EHD43-06 8/01/16 WELL/PUMP PERMIT <br />