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1k, <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 GALL <br />(ZU9 Ub3-/by f FOR INSPECTIONS r_ArIKCJ t T LAK I-KUm vH i t waUMU <br />JOB ADDRESS 14-1 <br />/ %/t If 1 CITY/ZIP Q <br />1 v–S <br />CROSS STREET im) APN�© y J �S C 3� PARCEL SIZE –SLAND USE APPLICATION# <br />OWNER NAME J /�✓& Co,(_ /� ��'� PHONE �0l <br />OWNER ADDRESS CITY/STATE/ZIP `, [� <br />CONTRACTOR �� Gr.OSS 00-1LZ h'1 �� SPHOONE J/�J 7 ` 7 <br />CONTRACTOR ADDRESS <br />� d / 3 C-/ 1 _7�� CITY/STATE/ZIPy�/ �� elzl'o i <br />SUBCONTRACTOR T1 �r'O 1–V Y►^� PHONE T.,7- 3 <br />SUBCONTRACTOR ADDRESS <br />LICENSE Wc:t: 57 ❑ C-61 ❑ D-09 ❑ Other <br />CITY/STATE/ZIP <br />NUMBER '37-73 1EXPIRATION DATE 6-1-1 <br />DOMESTIC WELL SAMPLING: 1 General Mineral/Coliform Bacteria (4391) 1 Dibromochloropropane (4392) I Arsenic (4393) <br />INTENDED USE ❑ Domestic/Privaterigation/Agricultural ❑ Industrial Ll W <br />❑ Vv <br />ter Quality Monitoring L) Soil Sampling/Characterization <br />c^ ( Cali <br />Public Water Syste ��� 1JQi <br />If different from Owner: Water System Name Contact Name or Phone Number <br />TYPE OF WORK OKNeW Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other <br />❑ Monitoring Well(s) # of wells ❑ Soil Boring(s) # of borings [--IGeotechnical # of borings <br />[I Out -Of -Service Well 11 Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />se"rew Pump ❑ Pump Replacement ❑ Pump Repair D Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method S6ud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other <br />Proposed Well Depth %C' ft Excavation 1 -2- in diameter i I Open Bottom ❑ Gravel Pack/Gravel Size_ <br />❑ Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter '6 in Thickness/Gauge/ASTM Sched ❑ Steel %-ePlastic ❑ Stainless Steel ❑ Other <br />in diameter <br />Grout Seal Depth�L t ❑ Neat Cement (94 /b bag/5-10 gal water) F1'$— nd Cement sack mix/7 gal water <br />❑ Bentonite (20% solids) ❑ Other <br />Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other 1 Retardant / Accelerator (name) <br />PEDESTAL Installed By Driller ❑ Pump Contractor ❑ Other <br />[I Concrete Pedestal []Dimensions: Width / ft Length ft Thick in ❑Christy Box ❑Stove Pipe <br />PUMP .XSubmersible❑ 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 />MINIM M 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />SIGNED .2f?� - TITLE O Cru a s-/- DATE g- � �' 1 <br />Application Accepted By <br />Grout Inspection By <br />Pump Inspection By <br />Soil Boring Inspection <br />RTMENT U rE7�ONLY <br />Date v <br />Date <br />Date <br />Date <br />Area tlqEmployee ID# <br />SPECIAL Well Permit <br />WAIVER Received <br />Constructed Well Depth <br />M, Permit/ <br />Service Request# <br />ELA <br />m <br />m <br />D <br />0 <br />0 <br />m <br />m <br />ur <br />ft <br />EHD 43-06 8/01/16 WELL /PUMP PERMIT <br />