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t <br /> L WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 <br /> NON-REFUNDABLE P20,14 <br /> EER/MMIIiT'� 1 CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1/YEAR FROM /,DATTE ISSUED <br /> JOB'ADDRESS - 14 GA �11� n CITY/ZIP . ca �-j�✓ m <br /> D <br /> CROSS STREET V `V ZV A P N � ^ PARCEL SIZE V• AND USE APPLICATION# 0 <br /> OWNER NAME Gl I V 1 Lv':1� I �/ DO PHONE m <br /> OWNER ADDRESS 61 M (' <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP R /10/ � 6�� e ��� <br /> (�� <br /> CONTRACTOR n 1 � PHONE ' �� / 14) <br /> l CITY/STATE/ZIPS �F 1 A192* <br /> _ <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STAT <br /> E/Z <br /> IP <br /> LICENSE C-57 1 1 C-61 I I D-09 I1 Other NUMBER ' 4!— EXPIRATION DATE. `I <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391)11 Dibromochloropropane(4392) 1 Arsenic(439 <br /> INTENDED USE ❑ Domestic/Private [IIrrigation/Agricultural I I Industrial ❑ Water Quality Monitoring J Soil Sampling/Char Irl t' �r V 71 <br /> ublic Water System �� IV <br /> I <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other <br /> #of borings #of borAVIZf <br /> Ll Monitoring Well(s) #of wells Ll Soil Boring(s) 1.1 Geotechnical Q <br /> ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repairi OR0 OUNT, <br /> 11 New Pum [I Pum Replacement Li Pump Repair 11 Raise Well Casin TNDEp NTAL <br /> WELL CONSTRUCTION NT <br /> Drilling Method Mudotary, U Air Rotary 11 Auger I I Cable Tool Ll Push Point I Other <br /> rr <br /> Proposed Well Depth r L' ft Excavation i. r in diameter 1-1 Open Bottom Gravel Pack/Gravel Size in diameter <br /> ❑ Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diamete-r71�__ in Thickness/Gauge/ASTM Sched_2,bL) I i Steel r Plastic I I Stainless Steel ❑ Other <br /> Grout Seal Depth w L ft Li Neat Cement(94 lb bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water <br /> Bentonite(20%solids) Ll Other <br /> Grout Placement Method V Pumped ❑ Free Fall I l Other I I Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller )(Pump Contractor ❑ Other <br /> t1 Concrete Pedestal FIDime sions:Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe <br /> PUMP ❑ Submersible❑ Turbine I I Other I-IP 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 /> MI 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br /> SIGNED TITLE DATE / <br /> R <br /> EPARTMENT SE ONLY <br /> Application Accepted By e Date Z Area "L Employee ID# <br /> Grout Inspection By Date_ (�� ❑ SPECIAL Well Permit <br /> Pump Inspection By f, Date ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth 6 ft <br /> COMM NTS <br /> C i r t o w G Z` t <br /> PE SC Received Chec Amount Date Permit/ Invoice# Well ID# <br /> Codes Info By/A -'el-sh emitted Service Request# <br /> 31 <br /> D ?� <br /> EHD 43-06 8/01/16 WELL/PUMP PERMIT <br />