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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-6292(209)468.1420 <br /> NON-REFUNDABLE <br /> X—'1$01 1 WWW.$ ov.o( /ehd EXPIRES I YEAR FROM DATE ISSUED <br /> JOB ADDRESS CilFrv�Tn� <br /> " r 110P7'1 c/'', 9503a <br /> m <br /> �j D <br /> CROSS STREET 1 -'1�(1b{r Jr 4 RV ./API 6S f a Y�' PARCEL SIZE�°� LAND USE APPLICATION# O <br /> OWNER NAME 1\Q(/��x"C -7- ')(��(�'Q 1 ` //�PHONE G / m <br /> OWNER ADDRESS 1 7''•\'nF0 f f'\+ `\re C f� 1 C1TY/STATEZP lam'0t I A-1 C k 1 51�_3 D <br /> CONTRACTOR _--1�G 1 1 c ,'J[t I^ ` PHONE 3G9 n-8-779 <br /> CONTRACTOR ADDRESS �•Q 1ri>c q a CITY/STATERIP ('C' <br /> SUBCONTRACTORICONSULTANT PHONE <br /> SUBCONTRACTOR/CONSULTANT ADDRESS CITY/STATEZP <br /> LICENSE Y C:-67 D C-61 D-09 -Other NUMBER 1"gtl 383 EXPIRATION DATE 7_3 1 -02 <br /> BILLING PARTY: ❑OWNER /-CONTRACTOR SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391),?Dibromochlcropropane(4392)-:Arsenic(4393) <br /> INTENDED USE j(Domestic/Private ❑Inigation/Agricultural C Industrial Water Quality Monitoring 7 Soil Sampling/Characterization <br /> Public Water System <br /> I/different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK >CNew Well J Replacement Well Well AlterationlModification Other <br /> Monitoring Well(s) #of wells --'Soil Borings) s o`bonn9s _ Geotechnical A of borings <br /> Out-Of-Service Well - Out-Of-Service Well Renewal -Cross-Connection Repair <br /> New Pum -Pump Replacement Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method(Mud Rotary C Air Rotary Auger -Cable Tool .. Push Point Other <br /> Proposed Well Depth _ft Excavation I t? in diameter Open Bottom !,Gravel PaddGravel Size VA - in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter-G--in Thickness/Gauge/ASTM SchedC 00 -.Steel X Plastic ,J Stainless Steel Other <br /> Grout Seal Depth 100 ft Neal Cement(94 lb bag/5-10 gal water) X Sand Cement 1(},3 sack mix(7 gal water <br /> 11 Bentonite(20%solids) Other <br /> Grout Placement Method)4 Pumped J Free Fall Other L Retardant/Accelerator(name) <br /> PEDESTAL Installed By ><Driller Pump Contractor iOther <br /> Concrete Pedestal-Dimensions:Width�ft Length ft Thick in -.Christy Box Stove Pipe <br /> PUMP Submersible."Turbine L Other HP ? Pump Set_j0(Q ft Standing Water Level_12_Q_ <br /> -- 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 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> �,AINIMUM 488 HHflUftADVANCE NOTICE REQUIR/ED FOR INSPECTIONS-PLEASE CALL(209)95 -77,:2o <br /> 7 <br /> SIGNED TITLE DATE Q <br /> W <br /> e <br /> O ' S <br /> PAYME u2 <br /> RECEIV ,b <br /> Jb <br /> T <br /> SAN N�RONIME M <br /> HEALTH IA <br /> DEPARTMENT USE ONLY <br /> Application Accepted By < / Date Area Employee ID# <br /> Grout Inspection By Date 0 - SPECIAL Wel)Permit <br /> Pump Inspection By 1"ter r" ,L Date ❑ WAIVER Receive L-' <br /> Soil Boring Inspection By Date Constructed Well Depth <br /> rft <br /> COMMENTS ge-o C r ".11- 02-4 ` <br /> PE SC Received Check#/ Amount dePertnitl Invoice# WeII1D# <br /> Cos Info Cs h Remitted Service Re uestl4 <br /> g Date <br /> I OCL L <br /> �t 1 4IS-0W001010-T-1 <br /> 3`%") i 7:� <br /> I <br /> E11043-DO 6/112018 WELL/PIMP PERMIT <br />