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SAN JoAgUINCOUNTY ENVIRONMENTAL HEALTH DEPELUPUMP PERMIT <br />ARTMENT 1899 EAST HAZELTON AVENUE - STOCKTOH CA 95205 - (2091498J420 <br />NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS � <br />'�"� CrryMp . / IQ/ T;;3-3(0 <br />CROSS STREET%. _ APN LD U _ ` I DO_ O l O PARCEL S12E LAND'USE APPLICATION �t <br />OWNER NAME PHONE <br />*, <br />OWNER ADDRESS X CITY/STATEMP 1y 3 <br />C/ <br />�� I <br />C/ <br />CONTRACTOR 1 /� PHONE <br />fr <br />CONTRACTOR ADDRESShlolfCrrY/STATE/LP M l Ii/1 q <br />SUBCONTRACTOR PHONE <br />SUBCONTRACTOR ADDRESS CrTY/STATEZP <br />LICENSE C-57 D C-61 D D-09 ❑ Other NUMBER r /—/-- EXPIRATION DATE <br />DOMESTIC WELL SAMPLING: ❑ General MineraUColifomi Bacteria (4391) ❑ Dibromochloropropane (4392) D Arsenic (4393) <br />INTEMED USE ❑ DomesOrJPrlvateInigsUon/Agricultural D Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization <br />O Public Water System <br />If dNlemd from Ovmar. Water Syefem Name Canted Name or Phone Number <br />TYPE OF WORK New Well D Replacement Well D Well Atteration/Modificalion D Other <br />cn'tcrirg �4O(s) #elweb 7 Soi16ofing(s) fcdDa"%s D Gectechnical <br />❑ Out-Or-Servlce Well D Out-Cf-ServiceNell Renewal G Cross -Connecuon Repair <br />❑ New Pumo ❑ Pump RSDlacement D Pump Repair O Raise Well Casino <br />Drilling Method kMud Rola D Air Rotary ❑ Auger ❑ Cable Tool O Push Point ❑ Other <br />Proposed Well Depth MD ft Excava0on _ �l In diameter ❑ Open Bottom ❑ Gravel Pack/Gravel Size In diameter <br />❑ Conductor Casing In diameter / Conductor Casing Depth ft <br />Well Casing Diameter. In. Thlckness/Gaug.IASTM Schad -'2,00 OSIeel Plastic ❑ Stainless Steel ❑ Other <br />Grout Seel Depth ft 0 Neat Cement (94 Ib baq� 10 ger weled ❑ Sand Cement sack mix/T gel water <br />Bentonite (20% solids) 1 ❑ Other <br />Grout Placemen Method . Pumped D Free Fell ❑ Other ❑ Retardant / Accelerator (name) <br />PEDESTAL Installed By D Driller ❑ Pump Contractor ❑ Other <br />❑ Concrete Pedestal ❑Dlmenelons: Width R Length ft Thick In ❑ Christy Box D Stove Pipe <br />PUMP ❑ Submersible Turbine ❑ Other HP Pump Sal 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 CALFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPUANCE WITH ALL <br />WORKERS COMPENSATION LAWS. <br />IVIIWS 48 HO D EQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />SIGNED TITLE DATE <br />Application Accepted By <br />Grout Inspection By <br />Pump Inspection By <br />Soil Boring Inspection By <br />COMMENTS <br />DEPARTMENT USE ONLY <br />Date <br />Date <br />Date <br />Dale <br />Area 5 I? C, Employee ID# A <br />❑ SPECIAL Well Permit <br />❑ WAIVER Received <br />Constructed Well Depth ft <br />F SMF <br />EI VEO <br />ON' V CpU <br />�Fp ENr NrY <br />RTMEN� <br />EH043-M SNilie <br />