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r <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 CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> 'I j� N <br /> Joe ADDRESS 1 CITVZ /,P ✓ V0 m <br /> CROSS STREETt"w APN?Z I Opp-130 PARCEL SIZE-T-LAND USE <br /> /1 APPLICATION 1#n /s/L7r v <br /> V PHONE YO�• v"I W- �Y/J� m <br /> OWNER NAME ` p) yy��PH.N S (�/�/� yAr r��]� v, <br /> OWNER ADDRESS M I• V CITYISTATE/ZIP r I-LAV l 1.�`a- l/ <br /> %'/Y� N <br /> CONTRACTOR 1•{ /� r`i V -•PHONE ,A1 J✓�j���� <br /> CONTRACTOR ADDRESS 'l CITY/STATE0P�Sf"\ ��71 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITYISTATE/ZIP <br /> LICENSE C-57 C C-61 G D-09 D Other NUMBER EXPIRATION DATE <br /> DOMESTIC WELL SAMPLING:)(General Mineral/Coliform Bacteria(4391)X1 Dibromochloropropane(4392)❑Arsenic(4393) <br /> INTENDED USE omesticJPrivate n Irrigation/Agricultural ,Industrial rl Water Quality Monitoring n Soil Sampling/Characterization <br /> L� ;Public Water System <br /> If Oillerenl Iran o+mer. Water System Name Contact Name or Phone Number <br /> TYPE OF WORN New Well }K*keplacement Well n Well Alteration/Modification D Other <br /> 11 Monitoring Well(s) #of wells -1 Soil Boring(s) s of bOfMV. O Geotechnical r of boring. <br /> Out-Of-Service Well : Out-Of-Service Well Renewal O Cross-Connection Repair <br /> [ New Pump n Pump Replacement :I Pump Repair n Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method XMud R a , F-,Air Rotary ❑ I-,Auger Cable Tool I Push Point ❑ Other <br /> ryn 1 <br /> Proposed Well Depth V ft Excavation J2 _in diameter I i Open Bottom !,Gravel Pack/Gravel Size_in diameter <br /> L',Conductor Casing in diameter / Conductor Casing Depth / It <br /> Well Casing Diameter In Thickness/Gauge/ASTM Schad YO D I:Steel Plastic n Stainless Steel D Other <br /> Grout Seal De IhU_ft n Neat Cement(94 lb bagl5-10 gal water) C Sand Cement sack mix/7 gal water <br /> �entonite 20%solids) ❑Other <br /> Grout Placement Method Pumped ❑Free Fall n Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By _] Driller C Pump Contractor n Other <br /> I I Concrete Pedestal nDimenelons:Width It Length It Thick in n Christy Box n Stove Pipe <br /> PUMP L Submersible?Turbine ❑Other HP Pump Set ft Standing Water Level it <br /> 1 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. 1 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 /> MINII�E NOTICE REQUIRED FOR INSPECT ONS PLEASE CALL(209)'953-7697 <br /> 11531769�7j�/�f� <br /> SIGNED_ TITLE IN1 DATE OV' l�' YV✓" <br /> I <br /> 1 141 1 TA-1 <br /> T-4 <br /> 44 <br /> 110-1pq M <br /> N FO <br /> 2020 <br /> QV�N <br /> q Fpq T p ANT y <br /> I <br /> DEPARTMENT USE ONLY <br /> �' Date � r+" -J Area / rt Employee ID# <br /> Application Accepted By - > � <br /> Grout Inspection By Date O SPECIAL W@II P@rlTllt <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth It <br /> COMMENTS 1 S-41 xF rl(Ii' <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info ash Remitted I I Service Rpquest# <br /> j P- 4. $L 1 <br /> 4 11�5' � <br /> # 72 <br /> EHD a3-0B 8/01116 � /I / ) WELL/PUMP PERMIT <br />