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WELL/PUMP PERMIT <br />Pr <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />a <br />NVN-HEFUNDABLE PERMIT <br />L:ALL 1Uy UO3-!b9( FOR INSPECTIONS tAFIHt51 YEAR FRO/MUAUATE ISSUED <br />JOB ADDRESS <br />Check#/ <br />Cash <br />v CITY/ZIP &jy�� ec b4 <br />CROSS STREET <br />Permit/ <br />Service Request # <br />` 0 � � PARCEL SIZE ��LAND USE APPLICATION # <br />OWNER NAME <br />�(AAPN <br />/ <br />` v PHONE <br />OWNER ADDRESS <br />► \' r <br />/Y�/ <br />Lk V v' CITY/STATE/ZIP V <br />CONTRACTOR <br />PHONE ` U 0- <br />CONTRACTOR ADDRESS <br />r c/� <br />CITY/STATE/ZIP (/ �/ C �� <br />SUBCONTRACTOR <br />PHONE <br />SUBCONTRACTOR ADDRESS <br />CITY/STATE/ZIP <br />LICENSE C-57 <br />❑ C-61 ❑ D-09 <br />❑ Other NUMBER � EXPIRATION DATE <br />GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br />NTENDED USE 1XDomestic/Private -1 Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring Soil Sampling/Characterization <br />❑ Public Water System <br />If different from Owner: Water System Name Contact Name or Phone Number <br />TYPE OF WORK ❑ New Well i Replacement Well ❑ Well Alteration/Modification ❑ Other <br />I i Monitoring Well(s) # of wells ❑ Soil Boring(s) # of borings ❑ Geotechnical <br />I Out -Of -Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br /># of borings <br />New Pump Pump Replacement n Pump Repair ❑ Raise Well Casing <br />WELL CCONSTRUCTI N <br />Drilling Method i i Mud Rotary i Air Rotary ❑ Auger ❑ Cable Tool i 1 Push Point r' Other <br />Proposed Well Depth ft Excavation in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel Size in diameter <br />I ' Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑ Steel ❑ Plastic ❑ Stainless Steel ❑ Other <br />Grout Seal Depth ft 1-1 Neat Cement (94 Ib bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water <br />I Bentonite (20% solids) i Other <br />Grout Placement Method Pumped ❑ Free Fall Other Retardant / Accelerator (name) <br />PEDESTAL Installed By Driller ❑ Pump Contractor Other <br />i Concrete Pedestal Dimensions: Width It Length ft Thick in i Christy Box i i Stove Pipe <br />PUMP Submersible Turbine I i 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 CALIFORNI ONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH LL <br />WORKERS COM LAWS. <br />MUM 24 OUR O ICF. REQUIRED F CT_IOIyS - PLEASE CALL (209) 953- 697 <br />SIGNED TITLE DATE 72 <br />DEPARTMENT SE ONLY <br />Application Accepted By �� Date I <br />Grout Inspection By Date <br />Pump Inspection By Date <br />Soil Boring Inspection By //Date <br />COMMENTS A;D Licus) cA. W4.1 till ►iii �� <br />T <br />Area Employee ID0 <br />D SPECIAL W-1! Permit / <br />❑ WAIVER Received <br />Constructed Well Depth ft <br />PE <br />Codes <br />SC <br />Info <br />Received <br />B <br />Check#/ <br />Cash <br />Amount <br />Remitted <br />Date <br />Permit/ <br />Service Request # <br />Invoice # <br />Well ID# <br />EHD 43-06 WELL /PUMP PERMIT <br />4/30/12 <br />