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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 c��EXPIIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS L <br /> `L ]1'Vc 1 �w E?zi� m <br /> -W� + CITY/ZIP ( � <br /> CROSS STREET �1 APIN l �— I L')Il' - V40 PARCEL SIZE LAND USE APPLICATION# En <br /> A <br /> OWNER NAME F KfAd PHONE <br /> ( En <br /> OWNER ADDRESS �( CAV � CITY/STATE/ZIP% � id • Celrl— q �- <br /> CONTRACTOR01 <br /> Il i I/ PfHHO'NE /� '��'G� <br /> CONTRACTOR ADDRESS I ' CITY/STATE/ZIP (� � � �✓ �C <br /> SUBCONTRACTOR PHONE <br /> SU13CONTRAC__TO/R ADDRESS ( L'C�'I1TYYISTTA�TnE/ZIP o� <br /> LICENSE V C-57 I I C-61 I I D-09 I I Other NUMBER \W W 12— EXPIRATION DATE U' ✓ �I <br /> DOMESTIC WELL SAMPLING: 11 General MI eral/Coliform Bacteria (4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE ❑ Domestic/Private rrigation/Agricultural 11 Industrial I; Water Quality Monitoring i i Soil Sampling/Characrization <br /> =i Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Numb <br /> TYPE OF WORK LAeW Well ❑ Replacement Well CI Well Alteration/Modification U Other �A_ <br /> ❑ Monitoring Well(s) #of wells [I Soil Boring(s) _ #of borings I I Geotechnical nngs 9 <br /> 11 Out-Of-Service Well El Out-Of-Service Well Renewal ❑ Cross-Connection Repair 8gN jOq Z019 <br /> I] New Pum '1 Pum Replacement F1 Pump Repair F1 Raise Well CasingAF-F QUI <br /> vN <br /> WELL CONSTRUCTIONSTM pEp e/ql �' <br /> Drilling Method WlS ud Rota y [IAir Rotary l 1 Auger I Cable Tool L] Push Point i l Otherr �N <br /> Proposed Well Depth v ft Excavationj� in diameter I I Open Bottom M Gravel Pack/Gravel Size_�� in diameter <br /> ❑ Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter !— in Thickness/Gauge/ASTM Sched /id0 1 1 Steel /Plastic I I Stainless Steel I Other <br /> Grout Seal Depth ft U Neat Cement(94 lb bag/5-10 gal water) Vl Sand Cement - sack mix/7 gal water <br /> Bentonite y20%solids) ❑ Other <br /> Grout Placement Method Pumped I_i Free Fall rl Other I I Retardant/Accelerator(name) <br /> PEDESTAL Installed By C Driller I I Pump Contractor f I Other <br /> 11 Concrete Pedestal ❑Dimensions:Width ft Length ft Thick in 11 Christy Box I I Stove Pipe <br /> PUMP ❑ Submersible❑ 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 COMPENSATION LAWS. <br /> MI I U 8 DANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br /> SIGNED TITLE ' ��� DATE <br /> G <br /> I� <br /> —A lic <br /> V <br /> Ir <br /> U <br /> , N <br /> hr <br /> �r <br /> 0 <br /> ATA 111G <br /> A M E N T S E L Y <br /> Application Accepted By Date Area Employee ID# <br /> Grout Inspection By J<' fp Date ❑ $PE IAL Well Permit <br /> Pump Inspection By Date LJ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft`7 <br /> COMMENTS rf. � �C 6 7T <br /> PE SC Received Ch Amount Date Permit/ Invoice# Well ID# <br /> Codes Info ash <br /> Im <br /> Service Re uest# <br /> Z-1 <br /> EHD 43-06 8/01/16 WELL/PUMP PERMIT <br />