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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 95fCITY/ZIP <br /> 3-7697 FOR INSPECTIONS EX..�PrrREIS/1 YEAR FROM DATE ISSUED <br /> / �! - <br /> JOB ADDRESS f H` / m <br /> �f� D <br /> CROSS STREET AwPN V PARCEL SIZE��LAND USE APPLICATION# / 0 <br /> OWNER NAME / �� <"Nh /C PHONE <br /> OWNER ADDRESS CITY/STATE/ZIP <br /> CONTRACTOR - cPHO'NE1000, <br /> /������"+� <br /> CONTRACTOR ADDRESS �/1 /'iy.� /�� CITY/STATE/ZIP <br /> SUBCONTRACTOR /f' -f�a /-/lam/�-�I��/ PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE 57 61 ❑ D-09 El Other NUMBER L!�O EXPIRATION DATE <br /> -/Z <br /> �l <br /> DOMESTIC WELL SAMPLING: =i General Mineral/Coliform Bacteria(4391) i Dibromochloropropane(4392) i Arsenic(4393) <br /> INTENDED USE omestic/Private ❑ Irrigation/Agricultural ❑ Industrial [_l 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 ells) #of wells ❑ Soil Boring(s) #of borings ❑ Geotechnical #of borings <br /> ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> ❑ New Pump ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method ❑ Mud Rotary Ll Air Rotary El Auger ❑ Cable Tool Cl Push Point [I Other <br /> Proposed Well Depth_Z 6a ft-1 Excavation IZ— in diameter [I 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 G'L11 Steel U�Plastic ❑ Stainless Steel ❑ Other <br /> Grout Seal Depthft ❑ 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 ❑ Pumped ❑ Free Fall ❑ Other l Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Drillere,,Ions: <br /> mp Contractor [I Other <br /> [I Concrete Pedestal 0Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe <br /> PUMP ubmersible❑ Turbine ❑ Other HP Z- Pump Set v ft Standing Water Level •-ft <br /> 1 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 /> MI HMfAN,CCEE NOTICE REQUIRED FOR INSPECT!PNS - PLEASE CALL (209) 953- 697 <br /> SIGNED ` �f�y�f�i� l TITLE � C- L ^' DATE <br /> l <br /> i <br /> ii <br /> ` � L <br /> J <br /> 9 <br /> NJ <br /> EP RTMENT USE qNLY <br /> Application Accepted By Date Area Employee ID# <br /> Grout Inspection By " Date [ISPECIAL Well Permit <br /> Pump Inspection ByCa Date �1�� \ Z-C)\` ❑ WAIVER Received <br /> Soil Boring Ins ection By Date Constructed Well Depth ft <br /> COMMENTS T a L �T Lizip tI <br /> PAYMENT <br /> PE SC Received ck# Amount Permit/ <br /> Codes Ifo B Cash fitted a Date Service Re uest# Invoice ID# <br /> ncT0- <br /> HEALTH EPARTMENT <br /> EHD 43-06 8/01/16 WELL/PUMP PERMIT <br />