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• , WELUPUIMP PERMIT <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 /> JOB ADDRESS CITY/ZIP m <br /> 0 <br /> CROSS STREET APN PARCEL SIZE LAND USE APPLICATION# M <br /> m <br /> rn <br /> OWNER NAME PHONE N <br /> OWNER ADDRESS CITYISTATE/ZIP <br /> CONTRACTOR PHONE_ <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE -i C-57 I C-61 i D-09 i Other NUMBER EXPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE Domestic/Private i_I Irrigation/Agricultural Industrial 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 Well Replacement Well Well Alteration/Modification 1 Other <br /> I Monitoring Well(s) #of wells F Soil Boring(s) #of borings I I Geotechnical #of boring$ <br /> F 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 Method 1 Mud Rotary i,i Air Rotary I I Auger 1 1 Cable Tool Push Point I I Other <br /> Proposed Well Depth ft Excavation in diameter 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 I Steel o Plastic I Stainless Steel I Other <br /> Grout Seal Depth ft Neat Cement(94 lb bag/5-10 gal water) Sand Cement sack mix/7 gal water <br /> -1 Bentonite(20%solids) I Other <br /> Grout Placement Method ❑ Pumped ❑ Free Fall I Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller Pump Contractor Other <br /> Concrete Pedestal Dimensions:Width ft Length ft Thick in Christy Box i Stove Pipe <br /> PUMP i= Submersible I Turbine i 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 /> j0AQUiN COuN-0( GFD;NANCES, S-TATE '_AWw, ,"ND 1_'•.ES AND REGULATIONS. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAI I ANi iN COMIPLiAN 14"1.1i ;L_ <br /> WORKERS COMPENSATION LAWS. <br /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS- PLEASE CALL(209) 953-7697 <br /> SIGNED TITLE DATE <br /> T <br /> l� <br /> JA jU <br /> EN <br /> 14 <br /> r C Nry <br /> M <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date Area Employee ID# <br /> Grout Inspection By Date F SPECIAL Well Permit <br /> Pump Inspection By Date i I WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B Cash Remitted Service Request# <br /> EHD 43-06 WELL/PUMP PERMIT <br /> 4/30/12 <br />