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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 I CALL (2 99) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DA^T]E, ISSUED <br />JOB ADDRESS CA i Are it, <br />/L CITY/ZIP 'fW0415 <br />CJ <br />CROSS STREET A P N ' K PARCEL SIZEZ.O� LAND USE APPLICATION # C( �1 <br />OWNER NAME /v�� wjo�, PHONE�� 1 S 1� <br />OWNER ADDRESS 1 CITY/STATEIZIP 80 <br />(.�'✓! • • / 1 <br />CONTRACTOR k4T� e- LIMPHONE 21 /�2r <br />1 D <br />CONTRACTOR ADDRESS CITY/STATE/ZIP jft?j —j`- —! � 5 - <br />SUBCONTRACTOR n PH(SE ) /A <br />SUBCONTRACT R ADDRESS / <br />LICENSE C-57 ❑ C-61 ❑ D-09 ❑ Other <br />N <br />EXPIRATION DATE <br />)OMESTIC WELLSPLING: ❑General Mineral/Coliform Bacteria (4391) ❑Dibromochloropropane (4392) ❑Arsenic (4393) <br />Ir <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 Uontact Name or Phone Number <br />TYPE OF WORK ❑ New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other <br />Date Permit/ Invoice # Well ID# <br />Service Request # <br />El Monitoring Well(s) #of wells E] Soil Boring # of borings s) ❑ <br />f <br />QsGeotechnical A <br />1-1 Out -Of -Service Well E] Out -Of -Service Well Renewal ❑Cross -Connection Repair <br />REC El,V <br />ElNew Pump &Pump Replacement El Pump Repair E]Raise Well Casing <br />C <br />WELL CONSTRUCTION f <br />Drilling Method El Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point El Other <br />MAY 1 2� <br />Proposed Well Depth ft Excavation in diameter E] Open Bottom ❑Gravel Pack/Gravel'V <br />epth ft <br />in <br />iameter / <br />Well Casing Diameter ctor C inin Thickness/Gaudge/ASTM Sched ductor Casing DDSteel ❑Plastic E] Stainless Steel <br />JOA,_„_. Q qu-dbOkmeter <br />HEALTH ❑'O�thpr ARTMENT <br />Grout Seal Depth ft ❑ Neat Cement (94 /b bag/5-10 gal water) ❑ Sand Cement <br />sack mix/7 gal water <br />[:]Bentonite (20% solids) ❑ Other <br />Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other ❑ Retardant / Accelerator (name) <br />PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other <br />E] Concrete Pedestal dimensions: Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe <br />PUMP EySubmersiblenTurbine ❑Other HP Pump Set_= ft Standing <br />Water Level 0 5 It <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 />OTICE REQUIRED FO <br />SIGNED <br />t DE ARTMENT U E ONLY <br />Application Accepted By Date l <br />Grout Inspection By Date <br />Pump Inspection By Date76lb-o-17 <br />Soil Boring Inspection By Date <br />COMMENTS <br />LEASE CALL (209) (9j <br />DATE / <br />T <br />1 <br />m <br />D <br />0 <br />v <br />rn <br />m <br />in <br />in <br />Area48�7 - Employee ID# Cqb l d <br />❑ SPECIAL Well Permit <br />❑ WAIVER Received <br />Constructed Well Depth ft <br />PE SC Received CghAmount <br />Codes Info as Remitted <br />Date Permit/ Invoice # Well ID# <br />Service Request # <br />ZP7S 0 . <br />a �� J PO03 51 <br />EHD 43-06 8/01/16 WELL /PUMP PERMIT <br />