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/_ WELL/PUMP PERMIT P <br /> f <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT /� CALL 209 /99553--7697 FOR INSPECTIONS EXPIRES ') YEAR FROM DATE ISSUED <br /> JOB ADDRESS –/72(/(/t � /��—� CITY/ZIP- /;%? � c=' I/"'/ f m <br /> o� 2� l93PARCEL SIZE /-z�a Gy aG <br /> CROSS STREET , ^AP�N� f LAND USE APP/L�jICLATION#L / <br /> ��" O <br /> 'OWNER NAME ��l/� /��� PHONE OA6— O <br /> 1 n <br /> OWNER ADDRESS /l/�J /�jJ/JJ/'' t,;c) 7S�/�/ ��/ 1TY/STATE/ZIP <br /> CONTRACTORAftig y� PHONE <br /> CONTRACTOR ADDRESS �IZO CITY/STATE/ZIP <br /> ;s_5 ,(J GZlS <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS �– CITY/STATEE//ZIP <br /> LICENSE V-57 -61 ❑ D-09 Ll Other NUMBER v EXPIRATION DATE I <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE 45Domestic/Private I I Irrigation/Agricultural I Industrial 1 I Water Quality Monitoring ❑ Soil Sampling/Characterization <br /> ❑ Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK ❑ New WellReplacement Well ❑ Well Alteration/Modification LI Other <br /> F1 Monitoring ells) #of wells I I Soil Boring(s) #of borings [IGeotechnical�4g, <br /> Ll Out-Of-Service Well I I Out-Of-Service Well Renewal I7 Cross-Connection Repair E® <br /> ,VNew Pump n Pump Replacement i7 Pump Repair rl Raise Well Casing <br /> WELL CONSTR TION 8 <br /> Drilling Method.,?VMud Rotaryi/Aiir Rotary [I Auger Fl Cable Tool [I � <br /> Push Point ❑ Other ��AQUI <br /> Proposed Well Depth ZdV /I Excavation /Z in diameter a Open Bottom ',3 ravel Pack/GraveM4: rr ameter <br /> Conductor Casing in diameter / Conductor Casing Depth ft MENT <br /> Well Casing Diameter A in Thickness/Gauge/ASTM Sched_ n Steel ❑ Plastic Cl Stainless Steel IJ Other <br /> Grout Seai Depth j" ft ❑ Neat Cement 1941b:ay/5-10 ga/water) i_I Sand Cement sack mix/7 gal water <br /> ",IvIentonite(20%solids) ❑ Other <br /> Grout Placement Method r umped Li Free Fall ❑ Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller ump Contractor I I Other <br /> FJ Concrete Pedestal I 1 imensions:Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe <br /> PUMP submersible❑ Turbine 11 Other HP Pump Set—,/LTO ft Standing Water Level <br /> 1 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 H DVANCE NOTICE REQUIRED FOR! SPPEJ/CJTIIONS - PLEASE CALL (209) 95?-769 <br /> SIGNED TITLE DATE <br /> lot <br /> w <br /> D PA TMENYT /U Y <br /> t <br /> 4#�W <br /> Application Accepted By Date Area Employee ID# <br /> Grout Inspection By Date CI SPECIAL Well Permit <br /> Pump Inspection By Date L i WAIVER Received <br /> rig <br /> oil Boring Inspection By Date nstru ted Well Depth ft �f� <br /> COMM NTS # <br /> 6 U V v <br /> "�����' PE SC Received heck#/ Amount / Permit/ <br /> Code,§ I rAo as emitted Date Service Re uest# Invoice# Well ID# <br /> Z9 eg <br /> W <br /> EHD 43-06 13/01116 WELL/PUMP PERMIT <br />