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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-REFUND P NMI CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> /J N <br /> JOB ADDRESS [� CITY/ZIP +l6ir m <br /> CROSS STREET NMS .�/ ,A/PN �' PARCEL SIZE" c` LAND USE/APPLICATION# TFC A <br /> `�+/ny `� &� VILCl� Glr+`y v PHONE ! U — J to <br /> OWNER NAME <br /> OWNER ADDRESS Orr ICU CITY/STATE/ZIP <br /> CONTRACTOR PHONE 3 J f` <br /> CONTRACTOR ADDRESS 6 ''S CITY/STATE/ZIP <br /> SUBCONTRACTORCP Al "—t u� PHONE 0— r <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP J <br /> LICENSE ,,e-57 Li C-61 F1 :3 <br /> D-09 I I Other NUMBER ) -J EXPIRATION DATE -G <br /> DOMESTIC WELL SAMPLING: I General Mineral/Coliform Bacteria (4391) Dibromochloropropane(4392) I Arsenic(4393) <br /> INTENDED USE ❑ Domestic/Private rrigation/Agricultural ❑ Industrial I I Water Quality Monitoring CI Soil Sampling/Characterization <br /> ❑ Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK D44�New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other <br /> ❑ Monitoring Well(s) #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 Methodw4 Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool 1 Push Point ❑ Other <br /> Proposed Well Depth �11)1(; ft Excavation /Y in diameter 1=1 Open Bottom 30eGravel Pack/Gravel Size in diameter <br /> ❑ Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter 6 in Thickness/Gauge/ASTM Sched�2 2!T ❑ Steel Plastic ❑ Stain ess Steel 11Other <br /> Grout Seal Depth`_.- ft ❑ Neat Cement(94/b bag/5-10 gal water) ieSand Cement U'�� sack mix/7 gal water <br /> ❑ Bentonite(20%solids) ❑ Other <br /> Grout Placement Method-4- Pumped ❑ Free Fall ❑ Other _ ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By SWDriller CI Pump Contractor} ❑ Other <br /> ❑ Concrete Pedestal ❑Dimensions:Width % ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe <br /> PUMP AkLSubmersible IJ Turbine ❑ Other HPA-P 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 /> MIRIMU 244 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS -PLEASE CALL (209) 953-7697 <br /> SIGNED, TITLE �� DATE—1"14 <br /> v <br /> v - <br /> _B 0 5 MIR <br /> H LHEAT EN <br /> �. DEPARTMENT U 5 E ONLY <br /> Application Accepted By Date Z Area L e Employee ID# <br /> Grout Inspection By Date S' ❑ SPECT L Well Permit <br /> Pump Inspection By C fu-v\ C Date Qt l ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS CC <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info By Cash Remitted Service Request# <br /> 2 <br /> s� 4/ p 3. <br /> EHD 43-06 8/01/16 WELL/PUMP PERMIT <br />