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s WELL/PUMP PERMIT <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 D Z'A CITY/ZIP m <br /> CROSS STREET �r 3 D D <br /> /tiL� � APN PARCEL SIZE LAND USE APPLICATION# A <br /> OWNER NAME 4 A PHONE Q N <br /> OWNER ADDRESS X27 ',e4w CITY/STATE/ZIP <br /> CONTRACTOR / /i�/ r'//�/�/ /y/, 7�/�� PHONE 751_137/010 <br /> CONTRACTOR ADDRESS 2f � (�Z/ OX CITY/STATE/ZIP <br /> SUBCONTRACTOR ?V/n— <br /> �4" PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE -57 U C-61 ❑ D-09 I I Other NUMBER / EXPIRATION DATE /Al/ 1 <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) i Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE -eomestic/Private ❑ Irrigation/Agricultural 1.1 Industrial ❑ Water Quality Monitoring i_l Soil Sampling/CharacNe—w- <br /> If <br /> /IJ_Public Water System <br /> different from Owner: Water System Name Contact Name or Phone Number �jr <br /> TYPE OF WORK [I New Well ^eplacement Well ❑ Well Alteration/Modification ❑ Other MAV ry <br /> ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings I I Geotechnical a o ng?0'8 <br /> ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection RepairJOAQU/N C <br /> ew Pum ❑ Pum Re lacement n Pum Repair F1 Raise Well CasingN EN�RON► OUNTY <br /> WELL CONSTR CTION uEPgRTINENT <br /> + Drilling Method WMud Rotary ❑ Air Rotary I I Auger I i Cable Tool I Push Point I I Other <br /> Proposed Well Depth /90� ft Excavation /Z in diameter Il Open Bottom ravel Pack/Gravel Size in diameter <br /> I 1 Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter-b- in Thickness/Gauge/ASTM Sched_4:�4 7-0a 11 Steel Mastic I Stainless Steel ❑ Other <br /> Grout Seal Depth Z& ft ❑ Neat Cement(94 Ib bay/5-10 gal water) /1-1 Sand Cement sack mix/7 gal water <br /> ,>Aaentonite(20%solids) ❑ Other <br /> Grout Placement Method _ umped ❑ Free Fall I I Other Ll Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller XPump Contract / 1 Other <br /> 1 Concrete Pedestal ❑Di ensions:Widt ft Length ft Thick in F1 Christy Box LJ Stove Pipe <br /> PUMP ubmersible❑ Turbine F1 Other HP ?— Pump Set ft Standing Water Level "k <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 /> MIN O ANCE NOTICE REQUIRED FOR�)SP,Ey/C/T�I�ONS -PLEASE CALL (209) 953- 697 <br /> SIGNED TITLE �'I%Z%�-� DATE Z <br /> ^)ar <br /> lot <br /> ZL <br /> ULI <br /> EP RTMENT U E ONLY <br /> Application Accepted By DateVP Area Employee IDVA~ <br /> Grout Inspection By J Dat ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS�1�17dl2 �� <br /> PE SC Received heck Amount Date Permit/ Invoice# Well ID# <br /> C Info B ash Remitted Service Request# <br /> fl j 23 ► WPOO-3 3 <br /> ZZE7 5 ' 2 <br /> EHD 42-06 8/01116 WELL/PUMP PERMIT <br />