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D <br /> WELL/PUMP PERMITLEi-Bj, <br /> SAN JIOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CX - <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS a 1� G Lec,,dS4c nt_ V c. CITY/ZIP A cameo l CA m <br /> CROSS STREET J`���n I S APN o Q S PARCEL SIZE 2 LAND USE APPLICATION# o <br /> z <br /> /� m <br /> OWNER NAME �n1�� ^DG��n L cPHONE N <br /> OWNER ADDRESS �o 0 U U I D` CITY/STATE/ZIP d , , CA C1 5 a 4 a <br /> CONTRACTOR IIP D6 t 1'li tV) PHONE J G 1 —� -79 <br /> CONTRACTOR ADDRESS p C . 1;CA q a ' CITY/STATE/ZIP_&a 1+ 1 CA 9 5 C,32 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE C-57 C-61 U D-09 ❑ Other NUMBER L� D EXPIRATION DATE V I <br /> DOMESTIC WELL SAMPLING:I i General Mineral/Coliform Bacteria(4391)11 Dibromochloropropane(4392)17 Arsenic(4393) <br /> INTENDED USE A Domestic/Private I I Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characte�iQn <br /> I I Public Water System _ 4 <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK A New Well I Replacement Well I I Well Alteration/Modification n Other <br /> #of borings ba irgs 2,,, <br /> Z J <br /> I Out-Of-Service Well I I Out-Of-Service Well Renewal n Cross-Connection Repair SAN <br /> New Pum i Pum Replacement 1 I Pum Repair 1_I Raise Well CasingE Di Q,MN Cp <br /> WELL CONSTRUCTION 11" TN DEPARTMENT <br /> Drilling Method A Mud Rotary i Air Rotary ❑ Auger i I Cable Tool 1_I Push Point 1_I Other <br /> Proposed Well Depth C' ft Excavation 11 in diameter ❑ Open Bottom AGravel Pack/Gravel Size IJA in diameter <br /> I I Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter CP in Thickness/Gauge/ASTM Sched 62(k r410 I I Steel Plastic ❑ Stainless Steel ❑ Other <br /> Grout Seal Depth 100 ft i I Neat Cement(94 lb bag/5-10 gal water) 4 Sand Cement 10 sack mix/7 gal water <br /> I I Bentonite(20%solids) I I Other <br /> Grout Placement Method Pumped LI Free Fall 1 Other I Retardant/Accelerator(name) <br /> PEDESTAL Installed By XDriller 1 I Pump Contractor ❑ Other <br /> Concrete Pedestal nDimensions:Width�_ft Length___(LL_ft Thick in 11 Christy Box Ll Stove Pipe <br /> PUMP A Submersible 11 Turbine i i Other HP_ Pump Set 5 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 /> MINIM M 48 HOUR ADVANCE NOTICE REQUIRED FORINSPECTIONS -PLEASE CALL (209)/953-769 <br /> SIGNED TITLEy 1 C c f S t e n DATE `7 q <br /> S <br /> nL'L <br /> C <br /> S <br /> DE ARTMENT WS/E O LY <br /> Application Acceptad By ` Date Area Employee ID#rAVk <br /> Grout Inspection By 6'nDate p5 k"I J PECIAL Well Permit <br /> Pump Inspection By �Cw�ll� Date I 1 WAIVER Received <br /> Soil Boring In4pecti n By Date Constructed Well Depth ft <br /> COMMENTS (XA J �© <br /> PE Sc Received hec Amount Permit/ <br /> o e Info sh emitted Date Service Re ues # Invoice# Well ID# <br /> LOV 06 <br /> EHD 43-06 8/01/16 WELL/PUMP PERMIT <br />