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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 /> Q C J rn <br /> JOB ADDRESS 1 T / CITY/ZIP Tr4q . 64 m <br /> cw D <br /> CROSS STREET Mme(_p��Ki / W— ^APN �L ��(O��j��' PARCEL SIZE 0.560 LAND USE APPLICATION A <br /> rn <br /> OWNER NAMEcn <br /> PHONE(51 0) 3C3 I 13340 <br /> OWNER ADDRESS �0 1k-e IL.� O - ff c Ti /STATE/ZIPS ♦ LrrA •��0 <br /> CONTRACTOR q,s�tot <br /> �+��1 1 Y,�•` • �,PH/ONE <br /> CONTRACTOR ADDRESS 1."t lloe S CITY/STATE/ZIP Mod Irate, Cg <br /> • <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE )(C-57 ❑ C-61 ❑ D-09 ❑ Other NUMBER EXPIRATION DATE <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE Domestic/Private [IIrrigation/Agricultural I I Industrial _I Water Quality Monitoring 1.1 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 ❑ Other <br /> ❑ Monitoring Well(s) #of wells Ll Soil Boring(s) #of borings I Geotechnical #of borings <br /> ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> ❑ New Pump ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION <br /> i A Rotary ❑ Air Rotary ❑1 Auger i I Cable Tool I I Push Point Li <br /> Drilling Method� <br /> Proposed Well Depth 100 ft Excavation 1 Z in diameter I I Open Bottom )(Gravel Pack/Gravel Size_in diameter <br /> ❑ Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter b in Thickness/Gauge/ASTM Sched 2-00 ❑ Steel Plastic I I Stainless Steel ❑ Other <br /> Grout Seal Depth2AI ft ❑ Neat Cement(94 Ib bag/5-10 gal water) ❑ Sand Cement sack r b(7 gal water <br /> d(8entonite(20%solids) ❑ Other <br /> Grout Placement Method Pumped ❑ Free Fall ❑ Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller VPump Contractor ❑ Other <br /> ❑ Concrete Pedestal F1 Dimensions:Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe <br /> PUMP ❑ Submersible[] 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 /> MI UM 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-76977 <br /> SIGNED TITLE DryA6t r DATE <br /> T <br /> S <br /> r X <br /> tXACIU1, 4 C U <br /> Et- <br /> 11 <br /> VAI Wt9t" D2TMENT U E ONLY <br /> Application Accepted By Date Area Employee ID#� <br /> Grout Inspection By Date C 1 SPECIAL Well Permit <br /> Pump Inspection By Date 1-1 WAIVER Received <br /> Soil Boring I�nsspecti n By I Date Co str ted Well De th 2-10 ft <br /> OMME1 V ( �Y <br /> - e( 0, �� Uprx <br /> Receiheck#l I "Kniduril Date Permit/ Invoice# Well ID# <br /> Codes III B 'Cash Remitted Service Request# <br /> 37 _ f �c <br /> EHD 43-06 8/01/16 WELL/PUMP PERMIT <br />