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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)468-7420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS I EXPIRES 1 YEAR <br /> dF/R FROM DATE ISSUED <br /> JUb MUUtttJJ 0 9(1 L <br /> `1 ��1 u I l y R til U I T/LIY ccam <br /> 0 <br /> CROSS STREET - �L L�1n <br /> ('�`,., APN �-�\� I yPSIZE LAND USE APPLICATION,ARCEL T (CATIrON#r z { p <br /> OWNER NAME 1� J,1'I'L` r. ` r� �d(�V- ,� l��' I -PHONE <br /> OWNER ADDRESS I 1 1 L `' "V1—1 CITY/STATE/LP <br /> CONTRACTOR \d c1 ,� PHONE <br /> CONTRACTOR ADDRESS �.C� I) `T CITYISTATE/LP <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE )(C-57 �,C-61 i D-09 I Other NUMBER � 3 D/� EXPIRATION DATE <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE 1-DomesUdPdvate Irrigation/Agricultural _Industrial Water Quality Monitoring Soil Sampling/Characterization <br /> I Public Water System <br /> If different from Owner Water System Name Contact Name or Phone Number <br /> I I <br /> TYPE OF WORK /,New Well 1 Replacement Well ❑Well Alteration/Modification Other <br /> Monitoring Well(s) #of wells ❑Soil Bonng(s) #of borings Geotechniral #of borings <br /> Out-Of-Service Well [I Out-Of-Service Well Renewal Cross-Connection Repair <br /> New Pum , Pump Replacement ❑Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method x.Mud Rotary Air Rotary Auger Cable Tool Push Point Other <br /> Proposed Well Depth 36,5 ft Excavation�in diameter L Open Bottom >�Gravel Pack/Gravel Size VA- in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth R <br /> Well Casing Diameter(�-, in Thickness/Gauge/ASTM Sched C�k 2Cik ISteel % Plastic Stainless Steel Other <br /> Grout Seal DepthICO It ❑Neat Cement(94/b bag/5-10 gal water) Sand Cement�0-s sack mixl7 gal water <br /> Bentonite(20%solids) C Other <br /> f:.nnT Plarnmonf MnLhcd)(pi impf rd �Frnn C2II -- llihcr - Gofarrl�nl/Grwrnlcr nfnr/n�mnl <br /> I� I <br /> PEDESTAL Installed By >t-Driller r-.. Pump Contractor I Other <br /> Concrete Pedestal i IDimensions:Width�ft Length ft Thick in Christy Box Stove Pipe <br /> PUMP j4 Submersibleu Turbine i i Other HP Pump Set C l' It Standing Water Level <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 �I <br /> WORKERS COMPENSATION LAWS. <br /> W <br /> MINIMUM 48 HOUR—ADVANCE NOTICE REQUIRED FOR INSPECTIO(NS-PLEASE CALL(209)953-7697 f' <br /> SIGNED. -Lj L'��-� TITLE \; f l I lieDATE <br /> S <br /> )� �� I►y <br /> t <br /> Q� D <br /> Ci <br /> Ci <br /> r <br /> 1 <br /> EC r <br /> s > >✓ED <br /> 1-1-1 1 144 <br /> P 3 2018 <br /> CO DE PAr12TMENTCUSE� NIL yEg1 RpNMENTgN1 <br /> Application Accepted Ey V Date YY 1' Area Employee ID# EPq/'TMENT <br /> Grout Inspection By �1 Date 1 SPECIAL WBII Permit <br /> Pump Inspection By QCi u C 1Cjb'Mate l� L1 ❑ WAIVER Received <br /> Soil Bonnq_Inspection By - Date Comstructed Well Depth_ ft <br /> COMMENTS IQ'v � •N1 I.4 � CMZ � - X[Sf�Y.d Ind-�-t 4 <br /> PE SC Received Check#J Amount Permit/ <br /> Codes Info B Cash Remitted Date Service Re uest# Invoice# Well ID# /y//� �� <br /> �J�SO O5 i �i�•�v " <br /> 3`1 i <br /> EHD 43-06 revised 4/14/16 WELL/PUMP PERMIT <br />