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WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT <br />CALL 209 953-7697 FOR INSPECTIONS <br />EXPIRES 1 YEAR FROM DATEISSUED <br />JOB ADDRESS <br />1 CITYZP <br />/ v <br />—';77 LAND USE APPLICATION <br />APN 11 — � - 100 PARCEL SIZE 12--';771111411) <br />V l/ <br />CROSS STREET <br />( <br />0— <br />PHONEn'✓0fn��j 111 <br />OWNER NAME <br />0 N C`� 5/� <br />OWNER ADDRESS /A, <br />CITY/STATElZ1PfMj <br />r <br />V <br />-/f 1 <br />2-04- 527- -IICW <br />CONTRACTOR N <br />%�/P/HOONE <br />7 <br />CONTRACTOR ADORESs I Ig <br />I fi rC rd CITY/STATEIZIP r <br />r I 0 i CA 1 ✓ :� ✓ <br />SUBCONTRACTOR <br />PHONE <br />SUBCONTRACTOR ADDRESS <br />CITYISTATEMP? <br />LICENSE C-57 ❑ C-61 <br />c: D-09 D Othef NUMBER -0022- <br />EAPIRATON DATE <br />DOMESTIC WELL SAMPt-m: A General Mineral/Coliform Bacteria (4391) 4 Dibromochloropropane (4392) ❑ Arsenic (4393) <br />sticJPrivate ❑ Irrigation/Agricultural 0 Industrial 0 Water Quality Monitoring 0 Soil Sampling/Characterization <br />INTENDED USE " <br />Public Water System <br />0 dReree from Owns- Waley System Hama Conlact Name or Ph n Number <br />TYPE OF WORK New Well ❑ Replacement Well 0 Well Akeration/Modification ❑ Other <br />Monitoring Well(s) s or wells 0 Soil Boring(s) s or borings 0 Geolechnical s or Ixxmgs <br />❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal Cross -Connection Repair <br />.. .. . . .......__ .,__�______. ., o......, o.....,/. n Reim Wall r'aemn <br />Drilling Method Mud Ro ❑ Air Rotary ❑ Auger [I Cable Tool ❑ Push Point ❑ Other <br />IfljProposed Well DepM t ft Excavation_ in diameter ❑Open Bottom 0 Gravel Pack/Gravel Size In diameter <br />0 Conduct Casing in diameter / Conductor Casing Depth It <br />Well Casing Diameter in Thickness/Gauge/ASTM SchedlL� ❑Steel testis ❑ Stainless Steel Ll Other <br />Grout Seal Depth It ❑ Neat Cement (94 lb bal;5-10 gal water) ❑ Sand Cement sack mix17 gal water <br />)(pentonile (20% solids) C Other <br />Grout Placement Method Pumped ❑ Free Fall 0 Other 0 Retardant / Accelerator (name) <br />PEDESTAL Installed By ❑ Driller 0 Pump Contractor ❑ Other <br />0 Concrete Pedestal ODimenslons: Width It Length ft Thick in 0 Christy Box ❑ Stove Pipe <br />PUMP ❑ Submersible Turbine C 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 />MI M 48 HOUR A VANCE NOTICE REQUIRED FOyRy IN1S�Pr E jTIIuO�(NS - PLEASE CALL (209) 953']-77697 <br />SIGNED � TITLE V 1 11 W � U\�1�vI- DATE 0'✓"1 •'A <br />DEPARTMENT USE ONLY <br />/L <br />Application Accepted By hal_ G. Date ` , '� Area ( r / Employee ID71 T! <br />Grout Inspection By Date ❑ SPECIALWell Permit <br />Pump Inspection By Data ❑ WAIVER Received <br />Sal Boring Inspection B1� Dom Constructed Well Depth ft <br />COMMENTS ,-r'� •l+Ttt L�'v ^'L' LIElr`NI i IS Y]Ft`?l F'r r LK"- C <br />T <br />O <br />m <br />w <br />EHD 43-00 M1/19 n I 12300J <br />_ � WELL /PUMP PERMIT <br />E= <br />rWIIZ�M►,�LVJMM���Is. <br />EHD 43-00 M1/19 n I 12300J <br />_ � WELL /PUMP PERMIT <br />