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t <br /> V�4 WELL/PUMP PERMITSAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)4 (/ U <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS y�J a7 J l G�� '^AP( CITY/ZIP e d~/ �.7�O 6�y <br /> CROSS STREET S"e x,"FL APN Z-z q O.5V RPARCEL SIZE 1Z LAND USE APPLICATION# 3 <br /> V / A <br /> OWNER NAME C C'/'(�" ��{'j-��I_ fin(art/ y/PHONE C�7 �()Cj- O k 10 ,Pe, <br /> OWNER ADDRESS Z J J J Ar , "Ur '" `- CfTY/$TATE/ZIP I./S�c2 ` / 'r��� <br /> CONTRACTOR r/eq�r/n/P. s/ �5'k MITh�_ PHONE Offf.) <br /> CONTRACTOR ADDRESS CRY/STATE2P 69T L,/ C-4�/�T�- <br /> 2s6s6 <br /> I <br /> SUBCONTRACTOR 11-117d`LL ^ PHONE <br /> SUBCONTRACTOR ADDRESS CRY/STATTJZIP <br /> LICENSE f�,C-57 n C-61 n D-09 n Other NUMBER ExPiRAT1ON DATE <br /> DOMESTIC WELL SAMPLING:-1 General Mineral/Coliform Bacteria(4391)n Dibromochloropropane(4392)-1 Arsenic(4393) <br /> INTENDED USE X Domestic/Private n Irrigation/Agricultural n Industrial n Water Quality Monitoring n Soil Sampling/Characterization <br /> F1 Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK n New Well n Replacement Well I Well Alteration/Modification n Other <br /> Fl Monitoring Well(s) #ofwelis -1 Soil Borings) #ofbodngs n Geotechnical #of borings <br /> n Out-OfServioe Well -1 Out-OfService Well Renewal n Cross-Connection Repair <br /> F1 New Pum lPump Replacement -1 Pump Repair n Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method n Mud Rotary n Air Rotary n Auger n Cable Tool n Push Point n Other <br /> Proposed Well Depth ft Excavation in diameter n Open Bottom n Gravel Pack/Gravel Size in diameter <br /> n Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_In Thickness/Gauge/ASTM Schad n Steel n Plastic n Stainless Steel n Other <br /> Grout Seal Depth ft n Neat Cement(94 lb bag/5-10 gal water) n Sand Cement sack m1xl7 gal water <br /> n Bentonite(20%solids) n Other <br /> Grout Placement Method n Pumped n Free Fall n Other n Retardant/Accelerator(name) <br /> PEDESTAL Installed By n Driller n Pump Contractor n Other <br /> F1 Concrete Pedestal nDlmenslons:Width R Length ft Thick in n Christy Box n Stove Pipe <br /> PUMP Submersibles Turbine n Other HP —?— Pump Set 1601 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 /> MINI UM 46 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED TITLE /:-i.G /C7,gyp✓ DATE <br /> PA <br /> Fe��® <br /> 2019 <br /> IV <br /> N Ull V COU IV <br /> C pAR MENT <br /> ,RIIEPA-RTMENT U E7ONLY�/ <br /> Application Accepted By VI`J Da4 / ! ` Employee ID# �� <br /> te � Area <br /> Grout Inspection By Date Fl SPECIALWell Permit <br /> Pump Inspection By Data fl WAIVER Received <br /> Sail Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC I Received Chec Amount ata Permit/ Invoice# Well IDS <br /> Codes Into --C%sh Remitted Service Re u t#- <br /> 0 W W3 <br /> EHD43-M revbad411411e WELL/PUMP PERMIT <br />