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WELL/PUMP PERMIT <br /> :.AN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 <br /> NEON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> Ln <br /> JOB ADDRESS CITY/ZIP m <br /> D <br /> CROSS STREET APN PARCEL SIZE LAND USE APPLICATION# o <br /> m <br /> m <br /> cn <br /> OWNER NAME PHONE ccn <br /> OWNER ADDRESS CITY/STATE/ZIP <br /> CONTRACTOR PHONE <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE FIC-57 ❑C-61 ❑D-09 ❑Other NUMBER EXPIRATION DATE <br /> DOMESTIC WELL SAMPLING:❑General Mineral/Coliform Bacteria (4391)❑Dibrornochloropropane (4392)❑Arsenic(4393) <br /> INTENDED USE ❑Domestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/ i ion <br /> ❑Public Water System <br /> If different from Owner Water System Name Contact Name or Frione Number <br /> TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification ❑Other 9 --.-j DD <br /> oo g <br /> El Monitoring Well(s) #of wells E]Soil Boring #of borings # fs) ❑Geotechnica��(1�a,__ <br /> ❑Out-Of-Service Well E]Out-Of-Service Well Renewal ❑Cross-Connection RepairPERM1TENTAL H <br /> L]New Pum L]Pump Replacement [-]Pump Repair E]Raise Well Casing ��T <br /> WELL CONSTRUCTION <br /> Drilling Method []Mud Rotary []Air Rotary ❑Auger ❑Cable Tool El 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 L]Other <br /> Grout Seal Depth ft ❑Neat Cement(94 lb bag/5-10 gal water) []Sand Cement sack mix17 gal water <br /> ❑Bentonite(20%solids) ❑Other <br /> Grout Placement Method ❑Pumped ❑Free Fall L]Other [-]Retardant/Accelerator(name) <br /> PEDESTAL Installed By []Driller El Pump Contractor ❑ Other <br /> E]Concrete Pedestal dimensions:Width ft Length ft Thick in []ChristyBox ❑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 LAMS, 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 DATE <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date Area_ Employee ID# <br /> Grout Inspection By _ Date ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> 11'a u 5 t2s r vt,r d- a 2 ;L C 14WI -2 6, <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info By Cash Remitted Service Request# <br /> EHD 43-06 8/01/16 WELL/PUMP PERMIT <br />