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s <br /> WELL/PUMP PERMIT I L, 1 <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 /> 99 / rn <br /> JOB ADDRESS �/ / l7 /, / C CITY/ZIP n(/ct, �rf G�22� m <br /> CROSS STREET/" iA�G (, APIN 0 (/ � 0 PARCEL SIZE LAND USE APPLICATION <br /> #p / ) S <br /> OWNER NAME r f�j' ( `/-7` L y,, , } PHONE /�/� vi <br /> OWNER ADDRESS [,O [ /1"0'1 <br /> p©CI '7"k wli_s + CITY/STATE/ZIP /1�V-3, <br /> � L'C�� l.Lf <br /> CONTRACTOR J(/�J/�t l PHONE J c� [ �� <br /> CONTRACTOR ADDRESS AD CITY/STATE/ZIP Cr I ce, <br /> SUBCONTRACTOR / � PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP ` <br /> LICENSE - C-57 [1C-61 F-1 D-09 E]Other NUMBER!, / 3�1' 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 System Name Uontact Name or Phone Number <br /> TYPE OF WORK QMew Well E]Replacement Well ❑Well Alteration/Modification E]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 /> „glew Pump ❑Pump Replacement ❑Pump Repair ❑Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method4:CMud Rotary ❑Air Rotary ❑Auger ❑Cable Tool E]Push Point ❑ Other <br /> Proposed Well Depth S Jb ft Excavation _ in diameter E]Open Bottomravel Pack/Gravel Size in diameter <br /> F-1ConductorCasing in diameter / Conductor Casing Depth ``'Gft <br /> Well Casing Diameter/O in Thickness/Gauge/ASTM Schad :Z 0 a ❑Steel Plastic ❑Stainless Steel ❑Other <br /> Grout Seal Depth Fya �Oft ❑Neat Cement(94 lb bag/5-10 gal water) Sand Cement sack mix/7 gal water <br /> ❑Benton ite(20%solids) ❑Other <br /> Grout Placement Metho Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller El Pump Contractor ❑ Other <br /> E)Concrete Pedestal[pimensions:Width_ ft Length ft Thick in ❑Christy Box ❑Stove Pipe <br /> PUMP pj�78ubmersible❑Turbina ❑Other HZ 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 COI-INTY 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 /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br /> SIGNED � � �� TITLE Q�� G� DATE Z Z— <br /> PAN J A UI C Wply <br /> ENV RCN EN TAL <br /> a <br /> DEPARTMENT USE ONLY <br /> Application Accepted By 7�AL Date 'ff� Area Cf Employee ID# <br /> Grout Inspection Bytit <br /> Sn Date 1 ❑ SPECIAL Well Permit <br /> Pump Inspection By Date n ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth J 3 ft <br /> COMMENTS <br /> PE Sc Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info By Cash Remitted Service Request# <br /> 43(; G u 3 r a a g <br /> N3ri0 c� S DL 3 W f 62i7 7 <br /> EHD 43-06 8/01/16 WELL/PUMP PERMIT <br />