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zV\ ti CCt_\ '2 -7 9,41 <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT CALL (209) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS <br />CROSS STREETVU,,LY,(�CAPN <br />IQ( -,I <br />��L <br />w I •. <br />D t <br />OWNER NAME 5_ <br />PARCEL SIZil__�� <br />LAND USE APPLICATION ##� <br />OWNER ADDRESS <br />PHONE Q/6'�1(`J�Q�`%ry/ <br />Je J <br />CONTRACTOR <br />CITY/STATE/ZIP <br />CONTRACTOR ADDRESS <br />PHONE(,//� <br />SUBCONTRACTOR <br />y <%4►���y <br />A <br />//II <br />ADDRESS <br />CITY/ZIP <br />PARCEL SIZil__�� <br />LAND USE APPLICATION ##� <br />PHONE Q/6'�1(`J�Q�`%ry/ <br />Je J <br />CITY/STATE/ZIP <br />PHONE(,//� <br />CITY/STATE/ZIP <br />y <%4►���y <br />PHONE I <br />CyrY/STATE/ZIP <br />LICENSE MC -57 [I C-61 ❑D-09 [j Other NUMBER'/j2 n((,C EXPIRATION DATE <br />DOMESTIC WELLS PLING: ❑General Mineral/Coliform Bacteria (4391) ❑Dibromochloropropane (4392) ❑Arsenic (4393) <br />INTENDED USE omestic/Private ❑ Irrigation/Agricultural ❑ Industrial [:)Water Quality Monitoring ❑ Soil Sampling/Characterization <br />❑ Public Water System <br />If different from Owner: Water System Name Uontact Name or Phone Number <br />TYPE OF WORK ❑ New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other <br />❑ Monitoring Well(s) # of wells ❑ Soil Boring(s) # of borings # of borings <br />❑ Geotechnical <br />❑Out-Of-Service,Vyell E] Out -Of -Service Well Renewal ❑Cross -Connection Repair <br />L] New Pump J&ump Replacement ❑Pump Repair E] Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method ❑ Mud Rotary ❑Air Rotary ❑Auger ❑ Cable Tool ❑ Push Point ❑ Other <br />Proposed Well Depth ft Excavation in diameter E] Open Bottom ❑Gravel Pack/Gravel Size_ <br />❑Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑Steel ❑Plastic E] Stainless Steel ❑Other <br />in diameter <br />Grout Seal Depth ft ❑ Neat Cement (94 Ib bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water <br />❑ Bentonite (20% solids) ❑ Other <br />Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other ❑ Retardant / Accelerator (name) <br />PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other <br />❑Concrete Pedestal dimensions: Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe <br />PUMP J1LSubmersible❑Turbine ❑Other HP / /cj,f Pump Set f ft Standing Water Level IW'71 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 />SIGNED <br />T <br />EPARTMENT USE ONLY ������,�// <br />Application Accepted By� Date Area R Employee ID# 6.GUf� <br />Grout Inspection By Date ❑ SPECIAL Well Permit <br />Pump Inspection By 1 Date ❑ WAIVER Received <br />Soil Boring Inspection By <br />COMMENTS <br />Date <br />Constructed Well Depth <br />ft <br />PE SC Received Check# Amount Date Permit/ Invoice # Well ID# <br />Codes Infopy as Remitted Service Request # <br />8 3 tpn SKOO wPoo3�277 <br />EHD 43-06 8/01/16 WELL /PUMP PERMIT <br />