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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 />Check#/ Amount Date Permit/ Invoice # Well ID# <br />Cash Remitte Service Request # <br />CALL 209 953-7697 FOR INSPECTIONS <br />EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS <br />I%� CITY/ZIP <br />`! n; <br />Y� q✓3 � r <br />CROSS STREET /, J V f- <br />u1 n <br />,• VQ— A LL <br />(� /�/ � <br />A P N Z. Z 1 V V V� � PARCEL SIZE) 77+LAND�CATION # <br />OWNER NAME C� <br />I -)-r <br />PHONE <br />OWNERADDRESS t;;-Zo <br />/"" <br />1 <br />V1S� <br />CONTRACTOR �'I�A'rt <br />CITY/STATE/ZIP <br />PHONE �C (J — 1 <br />51 AV <br />- 2 <br />CONTRACTOR ADDRESS <br />1 i CITYISTATE/ZIP <br />CA <br />� <br />SUBCONTRACTOR V a <br />rr <br />i <br />PHONE r%C <br />SUBCONTRACTOR ADDRESS—it! <br />l r to <br />j I✓ 1 CITY/STATE/ZIP <br />r Li t - t J �/ <br />LICENSE ),C-57 ❑ C-61 <br />❑ D-09 D Other NUMBER "" V <br />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 />D Public Water System <br />If different from Owner: Water System Name Contact Name or Phone Number <br />TYPE OF WORK ❑ New Well ❑ Replacement Well D Well Alteration/Modification ❑ Other <br />❑ Monitoring Well(s) # of wells ❑ Soil Boring(s) # of borings j( Geotechnical # of borings <br />❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />u Raise vveii <br />Drilling Method ❑ Mud Rotary ❑ Air Rotary -4 Auger ❑ Cable Tool ❑ Push Point ❑ Other <br />Proposed Well Depth ft Excavation in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel Size in diameter <br />❑ 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 rq[ Neat Cement (94 I6 bag/5-10 gal water) ❑ Sand Cement Sack mixf7 gal water <br />❑ Bentonite (20% solids) ❑ Other <br />Grout Placement Method I 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 ❑ Submersible[] Turbine ❑ Other HP Pump Set It 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. 1 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 />/MINIMUM HOU, ADVANCE NOTICE REQUIRED FOR IN`ryS`P}Fy-^CTIIONS - PLEASE CALL (209) 953-769 <br />SIGNED 1 `' TITLE I�'_'C ( '' jY' G'C� DATE <br />Application Accepted By <br />Grout Inspection By <br />EP RTMENT�Y <br />` Date <br />Date <br />Pump Inspection By Date <br />Soil Boring Inspection By Q�� Date <br />COMMENTS <br />Area Employee ID#i� <br />❑ SPECIA Well Permit <br />❑ WAIVER Received <br />Constructed Well Depth <br />PE SC Received <br />Codes Info B <br />Check#/ Amount Date Permit/ Invoice # Well ID# <br />Cash Remitte Service Request # <br />II )3, <br />EHO 43-06 8101116 WELL /PUMP PERMIT <br />