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w <br />` WELL/PUMP PERMIT I <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS CV <br />�j CITY/ZIPRAN — <br />CROSS STREET G L r Ia1 u / APN A L' � � �y � � PARCEL SIZE I 3 ; LAND USE <br />'A'PjPPLLICATION # ff <br />T lJ �� 1 <br />OWNER NAME PHONEt/ _% �J /^ <br />OWNER ADDRESS CITY/STATE/ZIP_M . (111%� A <br />CONTRACTOR PHONEy'M <br />CONTRACTOR ADDRESS94d-0 CITY/STATE/ZIP 6&kh /. 64 <br />SUBCONTRACTOR <br />SUBCONTRACTOR ADDRESS <br />LICENSE J-57 ❑ C-61 ❑ D-09 ❑ Other <br />PHONE <br />CITY//STATE/ZIP <br />NUMBER '! ^ i) �J lJ EXPIRATION DATE <br />)OMESTIC WELL SAMPLING: ❑General Mineral/Coliform Bacteria (4391) ❑Dibromochloropropane (4392) ❑Arsenic (4393) <br />NTENDED USE Domestic/Private ❑Irrigation/Agricultural ❑Industrial E] Water Quality Monitoring ❑Soil Sampling/Characterization <br />❑ Public Water System <br />If different from Owner: Water System Name Contact Name or Pbone Number <br />TYPE OF WORK ❑ New Well ❑ Replacement Well []Well Alteration/Modification ❑ Other <br />❑ MonitoringWell(s)—# of wells # of borings <br />El Boring(s) []Geotechnical <br />❑Out-Of-Servicet ell ❑Out -Of -Service Well Renewal ❑Cross -Connection Repair <br />E] New Pump &pympRQlaeement—'Pump Repair ❑ Raise Well Casing <br />WELL CONSTRUCTION <br /># of borings <br />Drilling Method ❑ ud Rotary ❑Air RotaryV <br />ble Tool ❑ ush Point ❑ Other <br />Proposed Well Dep ft Excavin diameter Open Bottom Gra I Pack/Gravel Size in diameter <br />❑ Con for Casing in nductor Casing De h ft <br />Well Casing Diameter in Thickness/Ga❑S el [-]Plastic ❑Stainle Steel ❑Other <br />Grout Seal Depth ft ❑ Neat Cement ( Ib bag/5-10 gal water) ❑ Sand Cement sack mixl al water <br />❑Bentonite(200o olids) ❑Other <br />Grout Placement Method ❑ Pum <br />❑ F.-ee Fall ❑ Other ❑ Retardant / Accelerator (name) <br />PEDESTAL In fled By EZDriller ❑ Pu��Contractor Other <br />❑Co Crete Pede imensions'11Vidth ft th Thick in ❑ qqristy Bo ❑Stove Pipe <br />PUMP Submersible ❑Turbine ❑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 />SUIT Irwpcction By <br />COMMENTS �i G <br />DEPARTMENT USE ONLY <br />Ll� Date <br />Date <br />Date 10 <br />DatC <br />>-4 Gss nr <br />Area J / �� �% Employee ID# 01 C c <br />❑ SPECIAL Well Permit <br />❑ WAIVER Received <br />Coi.struciad iicii Dept.' ft <br />Ti 76' <br />T <br />1 <br />m <br />D <br />0 <br />0 <br />m <br />m <br />ur <br />PE <br />Codes <br />Sc <br />Info <br />Received <br />B <br />Check#/ <br />Cash <br />Amount Permit/ <br />Remitted Date Service Request # Invoice # Well ID# <br />MT <br />2" 71 <br />1 sr✓? <br />7 P G-7 <br />EHD 43-06 8101116 WELL /PUMP PERMIT <br />