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SAN JOAOl1IN COUNTY ENVIRONMENTAL HEALTH DEPARTMWELL/PUMP PERMIT <br />ENT 1866 EAST HAZELTON AVENUE - STOCKTON CA 95205 -6232 (209) 468-3420 <br />NON-REFUNDABLE PERMIT 1AWW.S* OV. /ehd <br />C f7 — EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS � 5:7 X / Il. �. I _ 'iJ _A <br />-1A.4 1 N.4. CITY0P _ ( )JLXr�Y zz/15— <br />CROSS STREET � APN i <br />PARCEL SIZE LAND USE APPLICATION # <br />OWNER NAME.�k,ry ���� PHONE 2L4I �O _ r� <br />1n u <br />OWNER ADDRESS S � LW� � nr �/� ��-�..� /' r-7 <br />1 1 _ CITY/STATE/ZIP )lei ( <br />PHONE Z D� - P 3`1-3210 <br />CONTRACTOR ADDRESS 2. 12.0 <br />CIN/STATE/71P &ajz&� <br />SUBCONTRACTOR/CONSULTANT <br />PHONE <br />SUBCONTRACTOR/CONSULTANT ADDRESS <br />CITY/STATE/ZIP <br />LICENSE k C-57 C-61 D-09 Other([/ <br />NUMBER ` {D EXPIRATION DATE _ <br />BILLING PARTY: OWNER CONTRACTOR SUBCONTRACTOR/CONSULTANT <br />DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) _ Arsenic (4393) <br />INTENDED USE Domestic/Private Irrigation/Agricultural - Industrial Water Ouality Monitorin _ S l S <br />TYPE OF WORK <br />Public Water System 9 0l amphng/Charactenzatton <br />If drtferent from Omer. Water System Name <br />Contact Name or Phone Number <br />I— well Replacement Well Well Alteration/Modification Other <br />Monitoring Well(s) # of wells Soil Boring(s) # of bodngs <br />Geotechnical # of borings <br />Out -Of -Service Well Out -Of -Service Well Renewal Cross -Connection Repair <br />New Pump Jr Purnp Replacement Pump Repair <br />In"_ Raise Well Casino <br />!Drilling Method Mud Rotary Air Rotary Auger Cable Tool Push Point Other <br />Proposed Well Depth it Excavation <br />in diameter Open Bottom Gravel Pack/Gravel Size <br />Conductor Casing in diameter / in diaIme <br />Conductor Casing Depth ft <br />Well Casing Diameter_ in Thickness/Gauge/ASTM Scheel <br />Grout Seal Depth Steel Plastic Stainless Steel Other <br />p ft Neat Cement (94 /b bag/5-10 gal water) Sand Cement <br />Bentonite (20% solids) Other sack mixl7 gal <br />Grout Placement Method - Pumped - Free Fall - Other <br />_ Retardant /Accelerator (name) <br />PEDESTAL Installed By _ Driller Pump Contractor - Other <br />Concrete Pedestal Dimensions Width ft Length it Thick <br />n Christy Box Stove Pipe <br />PUMP J�Submerslble Turbine Other <br />HP Pump C ' Standing water Level <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. 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 />nAIN /�jUR CE NOTICE REQUIRED FOR JN�SP�JE/JCT�IONS - PLEASE CALL (209) 953- 97 <br />SIGNED r N ��' TITLE �/�''✓L-G <br />DATE Z / <br />Application Accepted By <br />Grout Inspection By <br />Pump Inspection By <br />Soil Boring Inspection By <br />COMMENTS <br />DETMENT SE ONLY J / <br />Date ' .l �- / C <br />Area Employee lD#� <br />Date SPECIAL Well Permit <br />Date <br />�Z/ WAIVER Received <br />Date Constructed Well Depth ft <br />rn <br />D <br />O <br />0 <br />m <br />41 <br />PA Y41, <br />VVIR�N NCOUN <br />TNz)t Qvp Tq� <br />' ,v r <br />WELL/PUI:.P PER IF <br />