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ti <br />"' !: 3ab /W= ,:& <br />C� �.� ;- •��� WELL/PUMP PERMIT <br />E0114 JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />hIOWREFUNDABLE PERMIT CALL (209) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />OB ADDRESSr / 10 CITY/ZIP <br />� tlC <br />CROSS STREET fJ�1 APN (/Q ! �l� - D� PARCEL SIZE 3AC LAND USE APPLICATION <br />'#�J y <br />OWNER NAME /", ` ! PHONE ClJ"''/ �/ <br />OWNER ADDRESS CITY/STATE/ZIP <br />CONTRACTOR el - <br />PHONE <br />CONTRACTOR <br />�/��� <br />CONTRACTOR ADDRESS `,/ �!J , �L CITY/STATE/ZIP-50rci[--/ <br />SUBCONTRACTOR �/2I/�/(/I� PHONE <br />SUBCONTRACTOR ADDRESS <br />LICENSE )C-57 ❑ C-61 ❑ D-09 ❑ Other <br />CIITAY/STATTE/ZZII P <br />NUMBER '/Az /06 EXPIRATION DATE <br />DOMESTIC WELL SAMPLING: [-]General Mineral/Coliform Bacteria (4391) ❑Dibromochloropropane (4392) ❑Arsenic (4393) <br />INTENDED USE Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial E] Water Quality Monitoring E] 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 Replacement Well ❑ Well Alteration/Modification ❑ Other <br />ElMonitoring Well(s) # of wells E]Soil Boring(s) # of borings E]Geotechnical # of borings <br />❑Out -Of -Service Well E] Out -Of -Service Well Renewal ❑Cross -Connection Repair <br />❑ New Pump ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method))Otlud Rotary <br />❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑ Other <br />Proposed Well Depth Z /�i ft Excavation 12-, in diameter ❑Open Bottom ravel Pack/Gravel Size in diameter <br />❑ Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter in <br />Thickness/Gauge/ASTM Sched 7 El Steel J�lastic ❑Stainless Steel ❑Other <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 umped ❑ Free Fall ❑ Other ❑ Retardant / Accelerator (name) <br />PEDESTAL Installed By ❑ Driller ;Wl'ump Contractor ❑ Other <br />F] Concrete Pedestal ❑dimensions: Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe <br />PUMP ubmersible❑Turbine ❑Other HPC Pump Set !?Cj'' ft Standing Water Level / ft. <br />I HEREBY CP4TIFY 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 U CE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7 97 <br />SIGNED TITLE_��/-� �� DATE % <br />Application Accepted By <br />Grout Inspection EK <br />Pump Inspection By <br />VJJ�t!P�j Employee ID# <br />SPECIAL Well Permit <br />❑ WAIVER Received <br />Soil Boring Inspection By Date nstructed Well Depth ft <br />COMMENTS — - A - r m <br />Z-! -X - L <br />T <br />m <br />D <br />v <br />v <br />m <br />m <br />PE Sc <br />Codes nfo <br />Cash <br />Aount Date <br />Remitted <br />Permit/ <br />Service Request # <br />Invoice # Well ID# <br />iReceivedm <br />S-b-il <br />S N' v3 <br />WF0 a oZ� <br />k 5-15 2- <br />-1 <br />r � <br />p1;-0 <br />k S-15 2 <br />p003tb (03 <br />`Zrla.C�=�tE- <br />EHD 43-06 8/01/16 i6 --'Y'. 11 %7t -"�' ` WELL /PUMP PERMIT ioe- <br />