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91 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 />JOB ADDRESS <br />Sc <br />Info <br />CROSS STREEiumT <br />Check#/ <br />Cash <br />Amount <br />Remitted <br />Date <br />Permit/ <br />Service Request # <br />OWNER NAME <br />Well ID# <br />v <br />OWNER ADDRESS <br />CONTRACTOR <br />CONTRACTOR ADDRESS <br />SUBCONTRACTOR <br />SUBCONTRACADDRESS <br />LICENSE IV 57 7 C-61 <br />[ 1 D-09 <br />GFnrnAPwre INcnRmATlnN- <br />Cnnrdinatpc X <br />CALL (ZU9) 9b3-/bUf FUH INbPt_l; I IUNA <br />I CITYIZIP U00 <br />APN I�/ y1 G ,l <br />/ �!/f) D / V PARCEL SIZE LAND USE APPLICATION # <br />rya CIC-) — �� <br />[l Other <br />Y <br />NUMBER <br />CITY/STATE/ZIP f <br />Vim/ I PHONE <br />CITY/STATE/ZIP 1- <br />PHONE <br />TE/ZIP <br />EXPIRATION DATE <br />Township Ranae Section <br />og <br />4TENDED USE Domestic/Private ❑ Irrigation/Agricultural U Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization <br />[l Public Water System <br />If different from Owner: Water System Name ontact Name or Phone Number <br />TYPE OF WORK [I New Well [1 Replacement Well ❑ Well Alteration/Modification ❑ Other <br />❑ Monitoring Well(s) If Of wells ❑ Soil Boring(s) # of borings ❑ Geotechnical of borings <br />❑ Out-Of-ServiceKump <br />ll U Out -Of -Service Well Renewal Ll Cross -Connection Repair <br />[_l New Pum Replacement ❑ Pump Repair ❑ Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method ❑ Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool U Push Point ❑ Other <br />Proposed Well Depth ft Excavation in diameter ❑ Open Bottom I. -I Gravel Pack/Gravel Size in diameter <br />❑ Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched U Steel Li Plastic ❑ Stainless Steel ❑ Other <br />Grout Seal Depth ft [l Neat Cement (94 lb bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water <br />I Bentonite (20% solids) � J Other <br />Grout Placement Method i 1 Pumped ❑ Free Fall F Other U Retardant / Accelerator (name) <br />PEDESTAL Installed By ❑ Driller 7 Pump Contractor ❑ Other <br />Concrete Pedestal � 'Dimensions: Width ft Length ft Thick in Cl Christy Box ❑ Stove Pipe <br />PUMP lySubmersible[! Turbine 1; 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 CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATION LAWS. <br />SIGNED <br />Application Accepted By <br />Grout Inspection By <br />Pump Inspection By _ <br />Soil Boring Inspection By _ <br />COMMENTS <br />Date <br />Date <br />Date <br />Area Employee ID#� <br />❑ SPECIAL Well 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 />