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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 PERMITT� At <br /> ` CALL(209) <br /> 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> AJOB ADDRESS / -10/1W /(2G� CITY/ZIP <br /> CC �j �"` m <br /> CROSS STREET �h � or*?-TP /?,KD APN ('t���L� --Z-4C;:pARCELSIZE 7�� 0 <br /> /� f� LAND USE APPLICATION# o <br /> OWNER NAME l�Q/���/4��r PHONE 701�yz cn <br /> OWNER ADDRESS /—C or 15/ cn=2 � 1 CITY/STATE/ZIP <br /> CONTRACTOR PHONE <br /> - CITY/STATE/ZIP <br /> CONTRACTOR ADDRESS /�zo a4K;� � CITY/STATE/ZIP <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP- <br /> LICENSE -57 -61 ElD-09 ❑Other NUMBER (J/G� EXPIRATION DATE O C <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391)❑Dibromochloropropane (4392)❑Arsenic(4393) <br /> INTENDED USE Domestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization <br /> ❑Public Water System <br /> If different from Owner: a er ys em Name Uontact Name or Phone Number <br /> TYPE OF WORK ❑New Well AR, eplacement Well ❑Well Alteration/Modification El Other <br /> ❑Monitoring Well(s) #of wells ❑Soil Borings) #of borings ❑Geotechnical #of borings <br /> E]Out-Of-Service Well E]Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> Mew Pum ❑Pump Replacement ❑Pump Repair [:]Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Methodlud Rotary ❑Air Rotary ❑Auger [-]CableTool ❑Push Point ❑ Other <br /> Proposed Well Depth :3�,V ft Excavation L' N in diameter ❑Open Bottom ravel Pack/Gravel Size /f in diameter <br /> ❑Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter� in T kness/Gauge/ASTM Sched e-04 7-60 ❑Steel Plastic ❑Stainless Steel ❑Other <br /> Grout Seal Depth ❑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 Mumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By JVDriller E]Pump Contractor ❑ Other <br /> El Concrete Pedestal dimensions:Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe <br /> PUMP ubmersible❑Turbine ❑Other HP Pump Seth ft Standing Water Level //S—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 /> MIN H DVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 95 -76?7 <br /> SIGNED /" ��L_ TITLE DATE II I <br /> i <br /> ITr< <br /> E RTMENT U E N L Y <br /> Application Accepted By Date u Area Employee ID#vW � <br /> Grout Inspection By Date / 11 ❑ SPECIAL Well Permit <br /> Pump Inspection By Date 0 t ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well DepthL1� ft <br /> COMMENTS <br /> PE Sc Received Amount Permit/ <br /> Codes, Ifo B Cash emitted D to Service Request# Invoice# Well ID# <br /> 6- �- <br /> S % / - <br /> aZI <br /> -7 ZLSM 7-77 <br /> pb--3,7 <br /> EHD 43-06 8/01/16 WELL/PUMP PERMIT <br />