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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 ZU <br />JOB ADDRESS <br />CROSS STREET - APN <br />t <br />OWNER NAME <br />9U( 129- '<Di <br />OWNER ADDRESS �/�/ +n <br />CONTRACTOR � / a A 11 <br />953-11159/ FOR INSPECTIONS <br />CONTRACTOR ADDRESS 212-0 1IA-hN(,0'4 )M ` <br />SUBCONTRACTOR <br />SUBCONTRACTOR ADDRESS <br />LICENSE X-57 ❑ C-61 ❑ D-09 <br />❑ Other <br />tAljlKtb 'I YEAR FROM UATE ISSUED <br />_ CITY/ZIP V J(A <br />1 M k ('j <br />CEL SIZE 2/ <br />LAND USEAP�PLL,IICATTI,O,N�^# <br />- <br />() (Q - <br />L(]jl ll0 <br />p <br />CITY/STATE/ZIP (� <br />/�PHH/ONE <br />�(/��rn , (� <br />I '1 <br />C . <br />PHONE G0`�I/- q� <br />l� 1�U <br />1� 0 <br />CITY/STATE/ZIP, <br />�ck-h , L.1 I <br />PHONE <br />CITY/STATE/ZIP_ <br />NUMBER <br />Wt <br />EXPIRATION <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 System Name Uontact Name or Phone Number <br />TYPE OF WORK ❑ New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other <br />El Monitoring Well(s) #of wells E] Soil Boring # of borings s) ❑Geotechnical # of borings <br />E] Out -Of -Service Well ❑Out -Of -Service Well Renewal ❑Cross -Connection Repair <br />[:]New Pum kump Replacement ❑ Pump Repair ❑ Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method E] Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool E] Push Point ❑ Other <br />Proposed Well Depth ft Excavation in diameter E] 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 ❑Steel ❑Plastic E] Stainless Steel E] 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) ❑ Other <br />Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other ❑ Retardant / Accelerator (name) <br />PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other <br />E] Concrete Pedestal Epimensions: Width ft Length It Thick in ❑Christy Box ❑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 />MI IOU ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br />�-`PEASE CALL (209) 951-7697 <br />SIGNED TITLE \WJ&+0Z DATE LP I `?, J I -F <br />LARMENT, MENT,l�j/�Y <br />Application Accepted By Dote /�_ / <br />Grout Inspection By Date <br />Pump Inspection By Date / 0 <br />Soil Boring / /ke!4iIIon B j Date <br />COMMENTS 19i7y71?f�/r�L <br />Ai <br />Area Employee ID#421110 <br />❑ SPECIAL Well Permit <br />❑ WAIVER Received <br />Constructed Well Depth ft <br />PE SC Received Check#/ Amount Date Permit/ Invoice # Well ID# <br />Codes Info B Cash Remitted Service Re ueSt # <br />TW 003 MP3 <br />EHD 43-06 8/01/16 WELL /PUMP PERMIT <br />