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WELL/PUMP PERMIT I <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVE -S COM- (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSP CTIONS E PIRES 1 YEAR FROM DATE ISSUED <br /> o� . � X y <br /> JOB ADDRESS ��L��(� `�� CITY/ZIP �" m <br /> D <br /> y/�oi APNTOjo'LAND USE APPLICATION# ACROSS STREETr y �� <br /> m <br /> a�� PHONE�i6 r6 0� <br /> OWNER NAME Cal n 'n <br /> OWNER ADDRESS O ax 3 CITY/STATE/ZIP nt• lJ'r �'�" �+ <br /> CONTRACTOR O /'ti�� C- rI�' PHONE <br /> CONTRACTOR ADDRESS .- CITY/STATE/ZIP <br /> SUBCONTRACTOR PHONE <br /> (-/1ti� PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> '? 6 <br /> r <br /> LICENSE kt C-57 11C-61 11D-09 L1 Other NUMBER / 3 EXPIRATION DATE L �.- <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane (4392) Arsenic(4393) <br /> INTENDED USE o4 bomestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization <br /> ❑ Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number t� <br /> TYPE OF WORK New Well ❑ Replacement Well 11 Well Alteration/Modification El Other <br /> i� <br /> ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings ❑ Geotechnical #of E® <br /> ❑ Out-Of-Service Well LI Out-Of-Service Well Renewal ❑ Cross-Connection Repair � P O <br /> ew Pum El Pump Replacement F1 Pump Repair F1 Raise Well Casing <br /> WELL CONSTRUCTION WiNJOAQU <br /> Drilling Method >CAud Rotary ❑ Air Rotary ❑ Auger C Cable Tool u Push Point Ll Other HEa f/ROIV p�UN <br /> Proposed Well Depth ii ft Excavation in diameter II Open Bottom Gravel Pack/Gravel Size PI f <br /> ❑ Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑ Steel XPlastic ❑ Stainless Steel L) Other <br /> Grout Seal Depth �� ft I l Neat Cement(94 Ib bag/5-10 gal water) ?Sand Cement i ra sack mix/7 gal water <br /> ❑ Bentonite(20%solids) ❑ Other " <br /> Grout Placement Method A<Pumped ❑ Free Fall ❑ Other I Retardant/Accelerator(name) <br /> PEDESTAL Installed By .*I Driller ❑ Pump Contractor ❑ Other <br /> ❑ Concrete Pedestal rlDimensions:Width ft Length ft Thick in Il Christy Box ❑ Stove Pipe <br /> PUMP < Submersible❑ Turbine I I Other HP__72` 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 /> MMez <br /> TITLE UM 48 OUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 9553-7697 <br /> SIGNED <br /> (/C.L//Lrf <br /> _ <br /> v <br /> J <br /> 1 <br /> n <br /> - PA f MEN 1 Ui= / NLY <br /> Application Accepted By Date ( Area Q Employee ID# <br /> Grout Inspection By to 2.1,7 q ❑ PECIAL Well Permit <br /> Pump Inspection By 1 iDate ❑ WAIVER Received <br /> Soil Boring Inspection By Date Co structed Well Depth 0 ft <br /> COMMENTS �� I �`; �.` <br /> I DO t <br /> i <br /> PE SC Received Ch Amount Permit) <br /> Code Info B Cash emitted Date Service Request# Invoice# Well ID# <br /> 00 3 S <br /> EHD 43-06 8/01/16 WELL/PUMP PERMIT <br />