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WELL/PUMP PERMIT <br /> SAW JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 <br /> NON-REFUNDABLE PER�+M►IIT� CALL 209 953-7697 FOR INSPECTIONS / EXPIRES 1 YEAR FROM DATE ISSUED LA <br /> JOB ADDRESS L/ C IP A/ m <br /> CROSS STREET mnel- t e'rAP,NvyZA <br /> i PARCEL SIZE LAND USE APPLICATION# A <br /> OWNER NAME L/ O /✓ /✓ PHONEPO <br /> OWNER ADDRESS �` CITY/STATE/ZIP AI/vim✓ c / <br /> CONTRACTOR PHONE <br /> ­5y� z�4 <br /> CONTRACTOR ADDRESS ZZ� //L'//��C /��s J CITY/STATE/ZIP <br /> SUBCONTRACTOR / /� L�� ��Y7 PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE 57 61 ❑ D-09 ❑ Other NUMBER c/ ,1 /C4 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 Sampli /Characterization <br /> ❑ Public Water System GATT/—):-- PA <br /> If different from Owner: Water System Name Contact Name or P <br /> TYPE OF WORK ❑ New Well VReplacement Well ❑ Well Alteration/Modification ❑ Other <br /> T 1�z,pj bor <br /> ❑ Monitoring Well ❑ <br /> Well(s) #of wells Soil Boring #of borings s) [IGeotechni C U18ings <br /> ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection �O <br /> ❑ New Pum ❑ Pum Replacement El Pump Repair ❑ Raise Well Casin AQU/N Cp <br /> WELL CONSTRUCTION EALTH pEPgRTTAL <br /> Drilling MethodyMud Rotary 0 Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other .4 <br /> Proposed Well Depth JCS 4/ Excavation l2 in diameter I I Open Bottom Gravel Pack/Gravel Size in diameter <br /> ❑ Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter 6 in T hickness/Gauge/ASTM Sched L 4'ZA9 F1Steel lastic ❑ Stainless Steel ❑ Other <br /> Grout Seal Depth_ ft ❑ Neat Cement(94 Ib 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 1 Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other <br /> ❑ Concrete Pedestal ❑Dimensions:Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe <br /> PUMP ❑ Submersible❑ Turbine 11 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 /> MIN��O�NCE NOTICE REQUIRED REQUIRED FOR INSPECTIONS -PLEASE CALL (209) 953'-7697 <br /> IGNED <br /> TITLE����/i'��C DATES S/ ` <br /> 3 <br /> y <br /> �J <br /> D P A qfT M E N T U E 0 N L Y <br /> Application Accepted By Date , Area Employee ID# <br /> Grout Inspection By <br /> e ❑ SPECIAL Well Permit <br /> Pump Inspection ByTELI Date ❑ WAIVER Received <br /> Soil Boring I , �eon By Dat Const Well Depth�ft <br /> COMMEN r <br /> / r n r w <br /> PE SC ReceivedAmount Permit/ <br /> Codes Info B C sh emitted Date Service Request# —invoice# Well ID# <br /> EHD 43-06 8101116 WELL/PUMP PERMn <br />