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L71 'Ailj1� 'TW <br /> �Mr WELL/PUMP PERMIT <br /> 4UIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 <br /> -jN-REFUNDABLE(�PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS ( y U f"l� <br /> CITY/ZIP 1 7E'"� m <br /> CROSS STREET [ / �1 APN Z ✓ ARCEL SIZE U AND USE APPLICATION# o <br /> ��,,� m <br /> OWNER NAME �:X �L`t (.L!Y'1 PHONE ai <br /> OWNER ADDRESS CITY/STATE/ZIP <br /> CONTRACTOR �PH(O(N�EOS'YG�G,`C/19-21- <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> �� Q <br /> l <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE C-57 [I C-61 Ll D-09 11 Other NUMBER 4i tP 16 b Z Z EXPIRATION DATE !/ <br /> DOMESTIC WELL SAMPLING:❑General Mineral/Coliform Bacteria(4391)❑ Dibromochloropropane(4392)❑Arsenic(4393) <br /> INTENDED USE Domestic/Private 1.1 Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization <br /> 1 ublic Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK New Well eplacement Well ❑ Well Alteration/Modification [I Other <br /> ❑ Monitoring W 1(s) #of wells ❑ Soil Boring(s) #of borings ❑ Geotechnical #of borings <br /> ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> 1-1 New Pump ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method >�Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool 1 Push Point ❑ Other <br /> Proposed Well Depth ?Gr, ft Excavation 12- in diameter ❑ Open Bottom >4ravel Pack/Gravel Size in diameter <br /> ❑ Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter—&in Thickness/Gauge/ASTM Sched Z-©Cf ❑ Steel Plastic ❑ Stainless Steel ❑ Other <br /> Grout Seal Depth Z06 ft ❑ Neat Cement(94 lb bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water <br /> X,3entonite(20%solids) ❑ Other <br /> Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller [11 mp Contractor ❑ Other <br /> ❑ Concrete Pedestal Li Dimensions:Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe <br /> PUMP 1 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 /> MINIMUM 4,8HOUR <br /> �ADVANCE NOTICE REQUIRED FOR INPPECTIONS -PLEASE CALL(209)953-7697 <br /> SIGNED ��(: ! l iC C k:�i+/ TITLE �.^I.1/�✓ DATE <br /> we <br /> f-AYI BT <br /> a <br /> r <br /> C U <br /> EP � <br /> D ' N, ENT SE 0- .4L Y <br /> Application Accepted By 4 Date e7 Area Employee ID# /" <br /> Grout Inspection By Date 10 LI PECIAL Well Permit <br /> Pump Inspection By Date 11 WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> floho <br /> PE Sc Received Check Amount Date Permit/ Invoice# Well ID# <br /> Codes Info By Cash Remitted Service Request# <br /> W v0 -A <br /> PEW - <br /> EHD <br /> -2�43-06 6/01/16 WELL/PUMP PERMIT <br />