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WELL/PUMP PERMIT <br />SAN:JOAQUIN 0-3UNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />-`4UN-REFUNDABLE PERMIT <br />CALL (ZO9) <br />953-7697 FOR INSPECTIONS 1 YEAR FROMDATE ISSUED <br />JOB ADDRESS <br />/d 1-n/% I , f <br />/ <br />1`2 f f/ / <br />��EXPIRES <br />CITY/ZIP 1 i ( Vq C' I , <br />/ j �' –Spc-� <br />CROSS STREET <br />�'.f�/�/ <br />1L " <br />PARCEL SIZE1j1�AND USE APPLICATION # <br />/ ^' / /�APN <br />L 0F <br />OWNER NAME <br />i [J 0(7 <br />�-+ 0,e <br />PHONE <br />OWNER ADDRESS <br />�(��j <br />(1d��^ <br />�In � <br />D <br />CITY/STATE/ZIP J/(��n <br />�JC> <br />CONTRACTOR <br />PHONE <br />(Yl�`, <br />CONTRACTOR ADDRESS <br />LJ It <br />CITY/STATE/ZIP <br />SUBCONTRACTOR <br />SUBCONTRACTOR ADDRESS <br />LICENSE XIC-57 ❑ C-61 ❑ D-09 ❑ Other <br />PHONE <br />CITY/STATE/ZIP <br />NUMBER �o EXPIRATION DATE <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: Water bystem Name Contact Name or Phone Number <br />TYPE OF WORKew Well E] Replacement Well <br />Monitoring Well(s) # of wells <br />E] Out -Of -Service Well <br />❑ Well Alteration/Modification ❑ Other <br />❑ Sou Boring(s) # of borings <br />❑Out -Of -Service Well Renewal <br />rum <br />❑ Geotechnical # of borings <br />❑ Cross -Connection Repair <br />naise vveii <br />Drilling Method ' Vlud Rotary ❑Air Rotary ❑Auger ❑Cable Tool El Push Point ❑ Other <br />Proposed Well Depth ft Excavation in diameter E] Open Bottom ❑Gravel Pack/Gravel Size in diameter <br />F-1 Conductor Casing in diameter / Conductor Casing Depth _ <br />Well Casing Diameter 7 in Thickness/Gauge/ASTM Sched El Steel <br />Grout Seal Depth 1067 ft ❑ Neat Cement (94 lb bag/5-10 gal water) <br />El Plastic E] Stainless Steel ❑Other <br />❑ Sand Cement <br />❑ Benton ite(20%solids) ❑Other <br />Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other ❑ Retardant / Accelerator (name) <br />sack mix/7 gal water <br />PEDESTAL Installed By ❑ Driller Pump Contractor ❑ Other <br />E] Concrete Pedestal Epimenslons: Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe <br />PUMP ($Submersible❑Turbine ❑Other HP I, N Pump Set rjf) ft Standing Water Level / n 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 />24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209)953-7697 <br />TITLE (�c� /. ,> F- 'c DATE G `�—lz <br />ARTMENT U E ONLY <br />Application Accepted By Date <br />Grout Inspection By Date <br />Pun:D Inspection By DP e _ d Z '1 <br />Soil Boring Inspection By I Date <br />COMMENTS <br />,r <br />Area 651�Employee ID#3 <br />n SPECIAL Well Pnrrnit <br />D WAIvFR Re,-teivorl <br />Constructed Well Depth <br />ft <br />PE Sc Received Check#/ Amount <br />Codes Info B Cash emitted Date <br />Permit/ <br />Service Request # Invoice # Well ID# <br />05"SCS <br />U�T 1013'` o3oce <br />EHD 43-06 8/01/16 WELL /PUMP PERMIT <br />