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WELL/P.UMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)466-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS Z �l.i fl> CITY(ZIP -rr7i <br /> J� D <br /> CROSS STREET i ` APN —� ✓ PARCEL SIZE LAND USE APPLICATION# <br /> _ m <br /> OWNER NAME J�� �) P ZONE <br /> OWNER ADDRESS —�--=•tom �i G ._ CITYISTATE21P_ `� O 1 I I O/�-•O .- ' V <br /> CONTRACTOR Moormah`S �Ncx..�-e,,� r PHONE I v I <br /> CONTRACTOR ADDRESS /M l CITY'STATE/ZIP <br /> 9 a <br /> SUBCONTRACTOR V r L ' `G -1 'I r"' I r 1Y C. PHONE <br /> SUBCONTRACTOR ADDRESS1--� CITY/STATEIZIP ('W� <br /> _12t <br /> LICENSE .0-57 D C-61 0 0-09 D Other NUMBER��Sf l to ExPIRATION DATE <br /> DOMESTIC WELL SAMPLING:IJ General Mineral/Coliform Bacteria(4391)0 Dibromochloropropane(4392)❑Arsenic( <br /> INTENDED USE 71%-Domestic/Private ;ii(Irrigation/Agricultural D Industrial 0 Water Quality Monitoring D Soil Sampling/ <br /> Public Water System _ EeFrv�r <br /> If different from Owner. Water System Name Contact Name or Phone Number Z� <br /> TYPE OF WORK �c New Well 0 Replacement Well 0 Well Alteration/Modification D Other <br /> ;!Monitoring Wells) #of wells 0 Soil Boring(,) #or bodnps D GeotechnicBMj #a, <br /> bann s <br /> J Out-Of-Service Well 0 Out-Of-Service Well Renewal 0 Cross-Connection Rep ait RO IN Nr� <br /> 0 New Pum 0 Pum Replacement 0 Pum Repair 0 Raise Well Casingf7 <br /> WELL CONSTRUCTION <br /> Drilling Method 49'Mud Rotary 0 Air Rotary D Auger 0 Cable Tool If Push Point 0 Other <br /> .Proposed Well Depth_.In Excavation 1,2-" in diameter 0 Open Bottom 0 Gravel Pack/Gravel Size ,.J&r• in diameter <br /> 0 Conductor Casing in diameter / Conductor Casing Depth it <br /> Well Casing Diameter67 in Thickness/Gauge/ASTM Sched '20t ❑Steel A Plastic 0 Stainless Steel ❑Other <br /> Grout Seal Depth 1013 n 0 Neat Cement(94 1b bag/S10 gal wafer) 0 Sand Cement sack mix(/gal water <br /> 4�Benlonile(20%solids) D Other <br /> Grout Placement Method PPumped 0 Free Fall 0 Other _ 0 Retardant/Accelerato,(name) <br /> PEDESTAL Installed By 0 Driller jl�Pump Contractor 0 Other <br /> D Concrete Pedestal ODimensions:Width ft Length It Thick in 0 Christy Box 0 Stove Pipe <br /> PUMP SubmersibleO Turbine 0 Other / HP Pump Set ft Standing Water Level—7-6—rt l <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 /> CURREN AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKE S OMPENSATION LAWS. <br /> II U 4 NCEl N.QTICE REQUIRED FO NSPECTIONS-PLEASE CALL(209)9$3-76q7 <br /> SIGNED 1 -�' ITITLE DATE <br /> .y <br /> (o <br /> c tT64 er /1 u W <br /> 7. <br /> ------ Eff 11 ---- <br /> ARTM EVTUE O LY <br /> .Application Accepted By at ?- l Area _ Employee ID# <br /> Grout Inspection By Date_. ❑ SPECIAL Well Permit <br /> Pump Inspection By Dale ❑ WAIVER Received <br /> Soil Boring Ins ection By e Constructed Well Depth ft <br /> COMMENTS l D�— <br /> PE SC Received Ch Amount Dale Permit! Invoice# well IDX <br /> Codes Info B Cash/ Remitted _ Service Request# <br /> 3( y0 x'22 7i <br /> c a <br /> EHD 41-06 8101/16 WELL/PUMP PERMIT <br /> f <br />