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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 /> fn <br /> JOB ADDRESS C CITY/ZIP I^S?lnL Ct W\ �i3 <br /> m <br /> CROSS STREET APN 113 - ��V PARCEL SIZE 1 OkLAND USE APPLICATION# / 7� /`( A <br /> OWNER NAME v 2✓c � o.� c- PHONE - �O^'b Tto <br /> p 1 <br /> OWNER ADDRESS G Z S �l \ �- CITY/STATE/ZIP C V v" A. / <br /> CONTRACTOR PHONE <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE [I C-57 ❑C-61 [I D-09 E]Other NUMBER EXPIRATION DATE <br /> DOMESTIC WELL SAMPLING:❑General Mineral/Coliform Bacteria (4391)❑Dibromochloropropane(4392)❑Arsenic(4393) <br /> INTENDED USE Domestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization <br /> ❑Public Water System <br /> If different from Owner: Water bystem Name Contact Name or Phone Number <br /> TYPE OF WORK QNew Well ❑Replacement Well ❑Well Alteration/Modification El Other <br /> ❑Monitoring Well(s) #of wells ❑Soil Boring(s) #of borings ❑Geotechnical #of borings <br /> El Out-Of-Service Well E]Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> %New Pump ❑Pump Replacement ❑Pump Repair ❑Raise Well Casing <br /> WELL CONSTRUCIIfON <br /> Drilling Method E]Mud Rotary E]Air Rotary ❑Auger ❑Cable Tool E-]Push Point ❑ Other <br /> Proposed Well Depth ft Excavation in diameter ❑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 Schad ❑Steel [-]Plastic [:]Stainless Steel ❑Other <br /> Grout Seal Depth ft ❑Neat Cement(94 lb bag/5-10 gal water) ❑Sand Cement sack mix/7 gal water <br /> ❑Bentonite(20%solids) F-1 Other <br /> Grout Placement Method ❑Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑Driller E]Pump Contractor ❑ Other <br /> ❑Concrete Pedestal Epimensions:Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe <br /> PUMP Submersible❑Turbine ❑OtherHP 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 /> \' INIM <br /> MINIMUM 24 H ADVANCE NOTICE REQUIRED FOR I PECTIONS - PLEASE CALL (209) 953-7697 r <br /> SIGNED 1 y /Gtr C" Q G-e cc' TITLE >C. w/�Jz 12 DATE f / <br /> Ivyq <br /> ✓l 'At_cc <br /> n// Y <br /> ' N <br /> DE ARTMENT U E NLY <br /> t �t <br /> Application Accepted By Date Area Employee ID#< 0L1L <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS P()kP 1 S /L(TT M1112/�'L C-V `�tT <br /> I - <br /> PE Sc Received Check#/ Amount Permit/ <br /> Codes Info Cas emitted Date Service Request# Invoice# Well ID# <br /> Q� .d17Df l oC� p0 l <br /> EHD 43-06 8/01/16 WELL/PUMP PERMIT <br />