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WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 -6232 (209) 468-3420 <br />NVN-KEFUNDABLE VERMII <br />JOB ADDRESS ` <br />CROSS STREET <br />OWNER NAME <br />OWNER ADDRESS Z / kyl 6- <br />www.slaov.ora/ena > <br />u -y/ LNIV—( CITY/ZZIIJP <br />APN�/�f `I L� IPARCEL SIZE QJ� <br />CITYISTATE/ZIP <br />tAljlKtb I YEAR FROM DATE ISSUED <br />USE APPLICATION # <br />PHONE <br />DOMESTIC WELL SAMPLING:x General Mineral/Coliform Bacteria (4391)AI Dibromochloropropane (4392), I Arsenic (4393) <br />NTENDED USE omestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring u Soil Sampling/Characterization <br />CI Public Water System <br />If different from Owner: Water System Name Contact Name or Phone Number <br />TYPE OF WORK Mew Well [Replacement Well H Well Alteration/Modification ❑ Other <br />❑ Monitoring Well(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 />Xew Pump ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br />Drilling Method ❑ Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point CI Other <br />Proposed Well Depth ft Excavation -L in diameter ❑ Open Bottom % Gravel Pack/Gravel Size in diameter <br />❑ Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter _Ic in Thickness/Gauge/ASTM Sched�LW ❑ Steel f lastic ❑ Stainless Steel ❑ Other <br />Grout Seal Depth 121-2 11Neat Cement (94 lb bagl5-10 gal water) 'lcSand Cement ,� sack mix17 gal water <br />❑ Bentonite (20% solids) ❑ Other <br />Grout Placement Method OPunlped ❑ Free Fall ❑ Other ❑ Retardant / Accelerator (name) <br />PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other on <br />❑ Concrete Pedestal ❑Dimensions: Width._ ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe <br />PUMP ubmersible❑ 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 />MINIMU 4 H VANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 963-7697 <br />SIGNED--! Z&—__ TITLE OW/IV- DATE J 1,6' <br />Pump Inspection By AP14J, Aaa Date 1-4-0 1-Z 02( WAIVER Received <br />Soil Boring Inspection By _ Date Constructed Well Depth <br />COMMENTS Exp nJe�e»�A1>7. muss 6e A % ,,"b),iw ue -9-C) eee+ tfrpm nFIZ 161It�j�___ <br />to <br />D <br />0 <br />0 <br />En <br />PE SC <br />Codes Info <br />Received hec Amount <br />B Cash Remitted Date <br />Permit/ <br />Service Request # Invoice # Well ID# <br />9379 1 0 <br />/ ab <br />L1361 <br />A I s0 <br />``) 3q <br />o <br />g3VO OSO <br />S� <br />i_rli.� I.>ucr �, I/Gu Iy VVGLL WUNW VLKNIII <br />