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i <br /> WELL/PUMP PERMIT L. <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS CA x CITY/ZIP � <br /> CROSS STREET /�/ S�<� �'"/ APN C%S/i�O�S PARCEL SIZ -� ) LAND USE APPLICATION# <br /> m <br /> OWNER NAME ^I- AL,KPHONE <br /> OWNER ADDRESS -?,A/"((�� �C CITY/STATE/ZIP <br /> CONTRACTOR /1 j- /` C JA�JAS PHO/NE <br /> y1� ( <br /> CONTRACTOR ADDRESS A /�+ 7 Z� CITY/STATE/ZIP <br /> SUBCONTRACTOR feC`i/ `/ 6412 PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE J/C-57 C-61 ❑ D-09 Other NUMBER��2� 1O�1 EXPIRATION DATE 6•- <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic(4393) <br /> INTENDED USE I i Domestic/Private I&<'Irrigation/Agricultural I I Industrial i I Water Quality Monitoring i i Soil Sampling/Characterization <br /> I Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK '*4tCNew Well ❑ Replacement Well ❑ Well Alteration/Modification IJ Other " <br /> #of borings o'l A�lap� ­ <br /> I I Monitoring Well(s) #of wells ❑ Soil Boring(s) I I Geotechnical � � I <br /> I Out-Of-Service Well CI Out-Of-Service Well Renewal ❑ Cross-Connection Repair n/C-70 <br /> flew Pump Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION � s <br /> Drilling Method-tfMud Rotary Air Rotary I Auger ❑ Cable Tool ❑ Push Point I! Other SAIV.JOAOVV�IRt� <br /> Proposed Well Depth ' ft Excavation in diameter r] Open Bottom ><Gravel Pack/GraV'9�i;y ON�_ 1�1EIvr�l�8meter <br /> ❑ Conductor Casing _ in diameter / Conductor Casing Depth ft AI?TIV <br /> Well Casing Diameter-d— in Thickness/Gauge/ASTM Sched� M <br /> i Steel astic Stainless Steel Other <br /> Grout Seal Depth <:, ft ❑ Neat Cement(94 lb bag/5-10 gal water) Sand Cement sack mix17 gal water <br /> Bentonite(20°/a solids) ❑ Other <br /> Grout Placement MethodX Pumped ❑ Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller I I Pump Contractor I_I Other <br /> Concrete Pedestal F1 Dimensions:Width:i�ft Length ft Thick in I I Christy Box I i Stove Pipe <br /> PUMP ZSubmersibleI 1 Turbine i Other HP Z07 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 /> MINIMgM 48 HOU ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br /> SIGNED le 111 TITLE�1421:*. DATE <br /> D EAR M E NT USE O N 1Y - <br /> Application Accepted By2C Date Area �l Employee ID# <br /> Grout Inspection By, Date �} I SPECIAL Well Permit <br /> Pump Inspection By _r Date 1 1 WAIVER Received <br /> Soil Boring Inspection By ` Date Constructed Well Depth ft <br /> COMMENTS b(L)AC V aM-6 i2T��y� W C4 �i�rJ ?= �" 1 c r l rY x �. <br /> PE SC Received ec Amount Permit/ <br /> Codes Info s e • Date Service Request <br /> # Invoice# Well ID# <br /> h! cIgo 0 <br /> O '�4� lq-3�7 <br /> 7 3 lUt 1 <br /> EHD 43-06 8/01/16 WELL/PUMP PERMIT <br />