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f ` � <br /> ' WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 <br /> 4 NON-REFU DABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRES /t� A 111 V w /"�/"' <br /> CROSS STREET VV1.IZ 1( APN •- 1300 V o <br /> L'�. ,y" PARCEL/SIZE •y LAND USE APPLICATION# <br /> OWNER NAME 5f(Q✓^ P^ �� V—C t l_ <br /> ,A\ � h PHONE <br /> OWNER ADDRESS 10100`ff i,(\ CITY/STATE/70!50"L&'� 61 11;21 le( w <br /> CONTRACTOR Ak-%PA <br /> PHONE �oeir [ (D0 <br /> CONTRACTOR ADDRESS 1 A S� C• CITYISTATE/ZIP 1✓U I� cA., 9,5632- <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATEJZJP <br /> LICENSE C-57 -i C-61 J D-09 l-Other NUMBER' O EXPIRATION DATE <br /> DOMESTIC WELL SAMPLING:CI General Mineral/Coliform Bacteria(4391):_Dibromochloropropane(4392)- Arsenic(4393) <br /> INTENDED USE - Domestic/Private ,Irrigation/Agricultural Industrial Water Quality Monitoring XSoil Sampling/Characterization <br /> Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK r New Well -.Replacement Well -I Well Alteration/Modification r�Other <br /> Monitoring Well(s) #of wells _:Soil Boring(s) #of borings Geotechnical •of borings <br /> j Out-Of-Service Well Out-Of-Service Well Renewal -Cross-Connection Repair <br /> ❑New Pump a Pump Replacement L Pump Repair L Raise Well Casing <br /> WELL CONSTRUCTION Y/y <br /> Drilling Method r_ Mud Rotary 1 Air Rotary XAuger Cable Tool _ Push Point Other <br /> Proposed Well Depth '2-5 it Excavation_�_in diameter - Open Bottom i Gravel Pack/Gravel Size indiameter <br /> 1 Conductor Casing in diameter / Conductor Casing Depth ft vc® <br /> Well Casing Diameter in Thickness/Gauge/ASTM Schad F Steel F_ Plastic ❑Stainless Steel ❑Other <br /> Grout Seal Depth ',-q it ,Neat Cement(94 lb bag/5-10 gal water) Sand Cement sack rn/AdWwater 9 <br /> Bentonite(20%solids) Other 01 <br /> J UCH ,J <br /> Grout Placement Method -Pumped G Free Fall �]Other C Retardant/Accelerator(name) N CD <br /> PEDESTAL Installed By I Driller -I Pump Contractor E Other -PgRN�CN�'�. <br /> Concrete Pedestal L Dimensions:Width It Length ft Thick in -Christy Box :i Stove Pipe MENT <br /> PUMP Submersible .Turbine Other HP Pump Set ft Standing Water Level it <br /> 1 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 /> UIM 48H J'�^/�/p'DVANCE NOTICE REQUIRED FOR INSCTIONS-APLEASE CALL(209) 53 697 <br /> SIGNED r — ,f TITLDATE <br /> =PTMENT U E ONL <br /> Application Accepted By to ea Employee ID#� <br /> Grout Inspection By Date SPECIAL Well P,mit <br /> Pump Inspection By Date I- WAIVER Received <br /> Soil Boring Inspection By Date L� Constructed Well Depth ft <br /> COMMENTS <br /> PE Sc Received Chec Amount Date Permit/ Invoice# Well ID# <br /> Codes Info emitted a ice Re uest# <br /> q-7441 <br /> EHD43-06 r—sed4/14/18 WELL/PUMP PERMIT <br />