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" WELL/PUMP.PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1866 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 <br /> NON-REFUNDABLE <br /> pPERMIT <br /> { CALL(209)953-7697 FOR INSPECTIONS n ,EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS , 1�Q t L IT I'Y N /G-LP. CITY/ZIP Roo" r G 9.5-361. <br /> m <br /> 1 rid, t�6 D <br /> CROSS STREET Carrel 4"F' 11j. APN VtS901+1 tl PARCEL SIZE�� 6 " LAND USE APPLICATION# <br /> j^� 7 m <br /> OWNER NAME \�fi71 f�'t PHONE <br /> OWNER ADDRESS ��!��(("?> C l- 4tA t 5P /�1 A At& CITY/STATE/ZIP h�-rce� rt <br /> V t <br /> CONTRACTOR + Pa�f I i l c r 1, t 1`1( y�r PHONE �'� r�7 Q <br /> CONTRACTOR ADDRESS I`� r-5 l� CITY/STATE/ZIP/ I Q� l", 9535:7 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP /, p <br /> LICENSE XC-57 ❑C-61 ❑D709 ❑Other NUMBER dI .EXPIRATION DATET 3/2.1 <br /> DOMESTIC WELL SAMPLING:❑General Mineral/Coliform Bacteria(4391)O Dibromochloropropane(4392)❑Arsenic(4393) <br /> INTENDED USE Domestic/Private ❑Irrigation/Agricultural ❑ Industrial ❑Water Quality Monitoring ❑Soil Sampling/Ch <br /> n�racterization <br /> ❑Public Water System (++I'iYM�;.�. <br /> If different from Owner: Water System Name Contact Name or Phone <br /> TYPEOF WORK )(New Well ❑ Replacement Well ❑Well Alteration/Modification ❑Other <br /> ❑Monitoring Well(s) #of wells 13 Soil Boring(s) of borings �❑Geotechnical j# fborings <br /> 2U� <br /> ❑Out-Of-Service Well 0 Out-Of-Service Well Renewal 0 Cross-Connection Repa g <br /> J J <br /> ❑New Pum [I Pump Replacement ❑Pum Repair ❑Raise Well CasingQAQUl <br /> WELL CONSTRUCTION HEALTH pEV eNTAL <br /> Drilling Method YMUd Rotary ❑Air Rotary ❑Auger ❑Cable Tool [I Push Point ❑ Other ' NEN <br /> Proposed Well Depth 3 G0 ft Excavation I Z in diameter ❑Open Bottom Gravel Pack/Gravel Size 24 in diameter <br /> ❑Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in ,Thickness/Gauge/ASTM Scheel -Go ❑Steel XPlastic ❑Stainless Steel ❑Other <br /> Grout Seal Depth 2 .CJS ft ❑Neat Cement(94 Ib bag/5-10 gal water) ❑Sand Cement sack mix/7 gal water <br /> �2"BenI it (20%solids) ❑Other <br /> Grout Placement Method Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑Driller Pump Contractor ❑ Other <br /> ❑Concrete Pedestal❑Dimensions:Width ft Length ft Thick in. ❑Christy Box ❑Stove Pipe <br /> PUMP ❑Submersible❑Turbine ❑Other HP Pump Set ft Standing Water Level ft <br /> I HEREBY CERTIFY THAT 1 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 /> WNIMUM 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209/)953-7)697 <br /> SIGNED ,�-a"-an- TITLE A/'r't'li" •" DA 6 -.F <br /> P <br /> P <br /> 20- <br /> \A -- <br /> c <br /> b <br /> d` <br /> DEPARTMENT U ENLY / <br /> Application Accepted By ..* -'/. Date "( Area 4" ` Employee ID#Ar C°. <br /> G�-,_ <br /> Grout Inspection B Date ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Receivedhec Amount Permit/Codes Info B ash Remitted Date Service Re uest# Invoice# Well ID# <br /> i$ '7 <br /> 4f2o (doll, LA <br /> EHD43-06 8/01/16 WELL/PUMP PERMIT <br />