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WELL/PUMP PERMIT <br />SAN JOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT I S0 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 488-3420 <br />NON-REFUNDABLE PERMIT CALL (209) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />ADDRESS CITYILP I r lur [[SzI , 1ULA !jV <br />:1 g kj <br />SS STREET N1 a <br />APN 2O - M <br />H O PARCEL SIZE LAND USE APPLICATION I <br />IER NAME <br />TI - <br />PHONE \ <br />/i <br />IER ADDRESS <br />t`l DD\ <br />CITY/STATErZIP <br />TRACTOR 1 r 1� <br />TRACTOR ADDRESS 111off <br />( 1 1 <br />PHONE <br />pv. <br />CITY/STATE t ^, <br />CONTRACTOR <br />PHONE <br />SUBCONTRACTOR /ZI <br />OR ADDRESS CITY/STATEP <br />/ <br />LICENSE .6 57 LJ C-81 ❑ D-09 D Othef NUMBER \1A g �P� EXPIRATION DATE <br />DOMESTIC WELL SAMPUNO: C General Mineral/Coliform Bacteria (4391) �- Dibromochloropropane (4392) ❑ Arsenic (4393) <br />INTENDED USE Domeatic[Private ❑ Irrigation/Agricultural n Industrial ❑ Water Quality Monitoring 0 Soil Sampling/Characterization <br />C Public Water System <br />If dilfenmt lean Owner Warm System Nemo Contact Nemo or Phew Number <br />TYPE OF WORK XNew Well 0 Replacement Well U Well Afteratlon/Modification ❑ Other <br />❑ Monitoring Well(s) # of wells 0 Sal Boring(s) a O1 wmgz 0 Geotechnical e OF Dorvgs <br />Cl Out -0f -Service Well ❑ Out -Of -Service Well Renewal 0 Cross -Connection Repair <br />D New Pump D Pump Replacement n Pump Repair 0 Raise Well Casino <br />Drilling MethodX�,.Mud Rot 0 Air Rotary 7 Auger) ❑ Cable Tool 0 Push Point ❑ Other <br />Proposed Well De It <br />Excavation in diameter n Open Bottom ❑ Gravel Pack/Gravel Siz in diameter <br />0 Conduct o Casing In diameter / Conduct r asing Depth fl <br />Well Casing Diameter.. n Thickness/Gauge/ASTM Schad ❑ Steel ,(Plastic 0 Stainless Steel ❑ Other <br />Grout Seal `D/eCCCth R 0 Neat Cement (94 Ib bag/r10 gal water) ❑ Sand Cement sack mix17 gal water <br />Bentonite (20% solids) 0 Other <br />Grout Placement thod Pumped 0 Free Fall 0 Other 0 Retardant / Accelerator (name) <br />PEDESTAL Installed By 0 Driller D Pump Contractor 0 Other <br />❑ Concrete Pedestal ODlmenslons: Width fl Length It Thick in 0 Christy Box C Stove Pipe <br />PUMP 0 Submersible0 Turbine n Other HP Pump Set R Standing Water Level It <br />1 HEREBY CERTIFY THAT 1 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 />MINI 48 HOUR AD NCE NOTICE REQUIRED FOR <br />,�INSPE TI (O�N,IS - PLEASE CALL (209 953-707 <br />SIGNED � � TITLEVI •1kk41� \` ,V lt#1 DATE _/ . ✓ / w 1 <br />Ll <br />O <br />0 <br />eC <br />�E YM�� T <br />C�jV ED <br />VA - 4 2071 <br />RON COUNTY <br />N �EPgAL <br />RT�IeNT <br />AMENT U E ONLY <br />/pvaAk '1 <br />Application Accepted By Area Employee IDI Date <br />Grout Inspection By Date ,a /2 J%�.0 ❑ PECI L WBII Permit <br />Pump Inspection By Date ❑ WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth AMW ft <br />COMMENTS L->i–�l— � 2 01 <br />►.'; 7n,'��1%.�J�I/tC�C�r�7F7�nlil1l�ii'�YY�L'�1i�:1�;1� <br />EHD 4}pe apt/te6r. r l f��30 / ) 7 <br />WELL HUMP PERMR <br />