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J <br /> ` 4 r�� I <br /> WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT I } Irj CALL 209 953-7697 FOR INSPECTIONS EX IRES 'I YEAR FROM DATE ISSUED <br /> 12 �� J CITY/ZIP I A ('r CR gs3�7 m <br /> JOB ADDRESS m <br /> CROSS STREET APN Cet1�l L3/ so PARCEL SIZB? `2­1�)LAND USE APPLICATION# <br /> bya,�ag� r I �(�� - 0`7- 240,0 <br /> m <br /> OWNER NAME �-�1+ U'C GM�I _Ambee /O W PHONE A 2 , <br /> OWNER ADDRESS �QS ��� h ' ` CITY/STATE/ZIP « • �/ <br /> CONTRACTOR I�aSe0li I rlltttj�A 2)\C ` PHONE � <br /> CONTRACTOR ADDRESS jtq <br /> A lb c rS CITY/STATE/ZIP ftvAIej-�dl CA "M57 <br /> SUBCONTRACTOR _ PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP w <br /> LICENSE XC-57 C-61 I D-09 Other NUMBER EXPIRATION DATE �G / <br /> DOMESTIC WIN SAMPLING:A General Mineral/Coliform Bacteria (4391) 1 Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE ^Domestic/Private ❑ Irrigation/Agricultural I I Industrial ❑ Water Quality Monitoring I I Soil Sampling/Characterization <br /> I I Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK XNew Well n Replacement Well 11 Well Alteration/Modification I 1 Other <br /> I i Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings I Geotechnical #of borings <br /> I I Out-Of-Service Well I I Out-Of-Service Well Renewal I I Cross-Connection Repair <br /> I I New Pump Pump Replacement I I Pump Repair I I Raise Well Casing <br /> WELL CONSTRUgZION <br /> Drilling Method Mud Rotary Air Rotary 11 Auger ❑ Cable Tool I I Push Point I Other <br /> Proposed Well Depth 300 ft Excavation in diameter Open Bottom XGravel Pack/Gravel Size <br /> in diameter <br /> Conducto Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter In Th/iickness/Gauge/ASTM Sched_200 I'i Steel ')(Plastic Stainless Steel Other <br /> Grout Seal Depth /40k .I Neat Cement(94 Ib bag/5-10 gal wate/) I' Sand Cement sack mix/7 gal water <br /> Depth <br /> to(20%solids) I l Other <br /> Grout Placement Method I umped LI Free Fall i I Other !I Retardant/Accelerator(name) <br /> PEDESTAL Installed By n Driller )Pump Contractor I I Other <br /> ❑ Concrete Pedestal []Dimensions:Width ft Length ft Thick in I i Christy Box I I Stove Pipe <br /> PUMP LI Submersible[] Turbine : Other HP 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 /> MINI UM 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br /> SIGNED TITLE J® ry'14'0", DATE A/"e'-1 7-45; <br /> tv� <br /> La <br /> 1 <br /> DEPARTMENT USE ONLY SAN,wAQUiNCOUNTY <br /> VOONMENTAL <br /> Application Accepted By Date I +� Area 3 J EF,�r�ji�e ID# <br /> Grout Inspection By �^�L— Date I C1 ( J :1 SPECIAL Well Permit <br /> Pump Inspection By Date !J WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS I t 9 [1.i l '✓ti L 1 � 1 i z 7 ( be,c <br /> PE SC Received eck Amount Permit/ <br /> Codes Info IB, ash Remitted Date Service Request# Invoice# Well ID# <br /> EHD 43-06 8/01/16 WELL/PUMP PERMIT <br />