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f WELL/PUMP PERMITREMij <br /> SAN hAQUIN COUNTY&,ARONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 <br /> NON-REFUNGABLE PERMIT E: CALL 09 953-7697 FOR INSPECTIONS //E PIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS !7 <` Ln <br /> L-10 CITY/ZIP `'f,�J r' m <br /> D <br /> CROSS STREET ( '' `p` J`-�S' APN .5- 0 ' PARCEL SIZE L_ LAND USE APPLICATION# o <br /> OWNER NAME ^ �- PHONE /— J ,�J Cn <br /> OWNER ADDRESS � CITY/STATE/ZIP \— � 1s �,,I,r, )�y <br /> CONTRACTOR ��� �� � ���lNS PHONE •—�sY—L �L— <br /> CONTRACTOR ADDRESSS / /°� �C CITY/STATE/ZIP <br /> SUBCONTRACTOR !`�y �j �f-�v��(^ ,/Y{// PHONE 7Lj— <br /> SUBCONTRACTOR ADDRESS CITY/STATEe//ZIP <br /> LICENSE C-57 ❑C-61 ❑D-09 ❑Other NUMBER X11 it EXPIRATION DATE <br /> DOMESTIC WELL SAMPLING:❑General Mineral/Coliform Bacteria (4391)❑Dibromochloropropane (4392)❑Arsenic(4393) <br /> INTENDED USE omestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization <br /> ❑Public Water System <br /> If different from Owner Water System ame ---------Conlact Name or Phone Number IVA <br /> TYPE OF WORK KNew Well ❑Replacement Well ❑Well Alteration/Modification ❑Other <br /> El Monitoring e /� <br /> , <br /> Monitoring Well(s) #of wells Soil Boring(s) #of borings V�Geotechnical 16.i <br /> ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal []Cross-Connection Repair Oct 16 <br /> New Pump ❑Pump Replacement ❑Pump Repair ❑Raise Well Casing Z <br /> WELL CONSTRUCTION JOAQUI <br /> DrillingMethod Mud Rota N ENVIRON NCOVN <br /> i Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑ Other Eig(Tc _ MFS,. 7Y <br /> Proposed Well Deptl;3`/0 ft Excavation _� in diameter El Open Bottom Gravel Pack/Gravel Sizep�RTct�h r <br /> ❑Conductor Casing in diameter / Conductor Casing Depth / ft <br /> Well Casing Diameter -6 in Thickness/Gauge/ASTM Sched2_t�c E]Steel Xastic E]Stainless Steel E]Other <br /> Grout Seal Depth `��ft ❑Neat Cement(941b bag/5-10 gai water) and Cement 1t) sack ivix17 gal waier <br /> ❑Bentonite(20%solids) ❑Other / <br /> Grout Placement Method,<Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By >RTDriller ❑Pump Contractor ❑ Other <br /> L]Concrete Pedestal dimensions:Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe <br /> PUMP ubmersible❑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. 1 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 /> MINIMU 244/H U DVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br /> SIGNEDI�JC/�'7� /�L TITLE lT/ CJCfJ)-,6 DATE <br /> J <br /> ,r <br /> n <br /> i <br /> i <br /> E ARTMENT U E( NL 1 / /"A�, <br /> Application Accepted By Date V l Area Employee ID#VV bf <br /> Grout Inspection By Date 7 la ❑ SPECIAL Well Permit <br /> Pump Inspection By Date r ❑ WAIVER Received 7 1 <br /> Soil Boring Inspection By Date /Constructed Well Depth > / ft <br /> COMMENTS�rM& J _FV01A (f&T /� Y <br /> PE Sc Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info Pyi Cash RjmiUPX Service Request# <br /> Mp <br /> �t I , I wf Z <br /> EHD 43-06 8/01/16 WELL/PUMP PERMIT <br />