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�f <br />s WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NUN-KEFUNDABL PERMIT (:ALL LUy !15J -/by/ FOR INSPECTIONS tXt' <br />JOB ADDRESS CITY/ZIP <br />CROSS STREET U. . APN� PARCEL SIZE LAND <br />,_ aA <br />OWNER NAME <br />OWNER ADDRESSMr; / " �' ITY/S /�TE/ZIP ' <br />CONTRACTOR MWW W&WK <br />CONTRACTOR ADDRESS=�V I�I �l CITY/STATE/ZIP <br />SUBCONTRACTOR <br />SUBCONTRACTOR ADDRESS CI Y/STATE/ZIP <br />LICENSE ❑ C-57 11C-61 11D-09 ❑ Other NUMBER <br />PHONE <br />I YEAR FROM DATE ISSUED <br />EXPIRATION DATE <br />TION # <br />'0gL-5(y24- <br />MK4_PldL4o = <br />DOMESTIC WELL SAMPLING: I I General Mineral/Coliform Bacteria (4391) i Dibromochloropropane (4392) I Arsenic (4393) <br />NTENDED USE Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ 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 />❑ Monitoring Well(s) # of wells ❑ Soil Boring(s) # of borings n Geotechnical # of borings <br />❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />❑ New Pump hPump Replacement ❑ Pump Repair ❑ Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method ❑ Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other <br />Proposed Well Depth ft Excavation in diameter I J 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 El Neat Cement (94 lb bag/5-10 gal water) ❑ Sand Cement sack mix17 gal water <br />❑ Bentonite (20% solids) ❑ Other <br />Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other 11 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 ft Standing Water Level ft <br />I HEREBY CER FY 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 />MINI M 2 U ADVANCE NOTICE REQUIRED FO¢ INSPECTIONS�PLEASE CALL (209) 95,7-769 <br />SIGNED TITLE �ICQIC DATE <br />Area Employee ID#�� <br />LI PECIALWell Permit <br />❑ WAIVER Received <br />Constructed Well Depth ft <br />W <br />m <br />n <br />0 <br />v <br />m <br />m <br />co <br />PE Sc Received Check#/ <br />Codes Info B Cash <br />EP TMENT U E NLY <br />' t <br />Application Accepted By <br />Date <br />s <br />Grout Inspection By <br />Date <br />" Date <br />Pump Inspection By <br />Soil Boring Inspection By <br />Date <br />COMMENTS <br />Area Employee ID#�� <br />LI PECIALWell Permit <br />❑ WAIVER Received <br />Constructed Well Depth ft <br />W <br />m <br />n <br />0 <br />v <br />m <br />m <br />co <br />PE Sc Received Check#/ <br />Codes Info B Cash <br />Amount <br />emitted Date <br />Permit/ <br />Service Request #IL <br />Invoice # Well ID# <br />s <br />EHD 43-06 8101/16 WELL /PUMP PERMIT <br />