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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 210 414 QP1 W-A u).q1 CITY/ZIP FICA I&A [Q/37–o m <br /> CROSS STREETAPN 2- l 4 — o <br /> V WuPARCEL SIZE 6 3LAND USE APPLICATION#(� A <br /> OWNER NAME DQ� �► !rte IV(`�_I�CZ -j'^P�HONE /(plD ��� 7/y��C 'n �? <br /> OWNER ADDRESS 2(4 L4 q `a}RCS�M� a� CITY/STATE/ZIP rj Ca10� r CA [J 3([/ <br /> CONTRACTOR '` � `{��1 31`t PHONE T22-11 Z`i <br /> CONTRACTOR ADDRESS 1 b e,, ,� CITY/STATE/ZIP ( - �od a S��C�25357 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE C-57 I I C-61 ❑ D-09 i Other NUMBER EXPIRATION DATE <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) n Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/ i _ation <br /> ❑ Public Water System � ��AAS ?• <br /> If different from Owner: Water System Name Contact Name or Phone <br /> TYPE OF WORK Ll New Well eplacement Well I I Well Alteration/Modification I I Other t//°r <br /> ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings I i Geotec"I a # �ngs <br /> ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal i l Cross-Connection R1, <br /> F1 F1New Pum El Pump Replacement F1 Pump Repair I I Raise Well CasingHEA[, ONci-jOVN <br /> WELL CONSTRUCTION A <br /> RTS t <br /> Drilling Method JIB Mud Rotary ❑ Air Rotary 11 Auger I I Cable Tool Push Point U Other <br /> Proposed Well Depth_ 2-(-/O _ft Excavation in diameter I I Open Bottom X <br /> Gravel Pack/Gravel Size in diameter <br /> Conduct r Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched I I Steel Plastic ❑ Stainless Steel I I Other <br /> Grout Seal Depth0-9 ft [I Neat Cement(94 Ib bag/5 10 gal water) 11 Sand Cement sack mix/7 gal water <br /> ento ite(20%solids) ❑ Other <br /> Grout Placement Method umped Free Fall i I Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By I I Driller I l Pump Contractor I I Other <br /> ❑ Concrete Pedestal I(Dimensions:Width ft Length ft Thick in I I Christy Box I l 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 /> M M 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br /> SIGNED TITLE x3rale"o- DATE A6 —12-10 <br /> G <br /> IN <br /> 0 <br /> RTMENT USErO LY01 <br /> Application Accepted By cY� Date J �� Area "L Employee ID#&W <br /> Grout Inspection By t I� Date '� ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring InspectionBy { Date Co ed Well Depth ft <br /> COMMENTS �� J�` LNC `/V/ <br /> PE SC Received a Amount Permit/ <br /> ode fo By_ ash emitted Date Service Request# Invoice# Well ID# <br /> A 31 <br /> ILL <br /> EHD 43-06 8/01/16 WELL/PUMP PERMIT <br />