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WELL/PUMP 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 /> C m <br /> JOB ADDRESS 1 a 14 r4- CITY21P " m <br /> CROSS STREET r r• APN I / 7�� v v 7 PARCEL SIZE LAND USE APPLICATION# A <br /> m <br /> OWNER NAME PHONE �N,+ <br /> OWNER ADDRESS CITY/STATE/ZJP F 2 <br /> CONTRACTOR I PHONE Q� O <br /> � (� `j <br /> CONTRACTOR ADDRESS O — �' �2' CITY/STATE/ZIP s''Qi;4 1�0''n- (rA 9S ea <br /> SUBCONTRACTOR Ir4 I PHONE�y� /y;c 70o <br /> SUBCONTRACTOR ADDRESS 1133 lack (, cst Dr. CITYISTATE/ZJP P Imo/ <br /> LICENSE j C-57 ❑C-61 ❑D-09 0 Other NUMBER ZV O y EXPIRATION DATE 3V ?,O <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391)0 Dibromochloropropane(4392)❑Arsenic(4393) <br /> F <br /> DED USE [IDomestic/Private ElIrrigation/Agricultural ❑Industrial D 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 0 Replacement Well ❑Well Alteration/Modification ❑Other <br /> ❑Monitoring Well(s) #of wells ❑Soil Borings) #of bodngs Geotechnical #of borings <br /> ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> ❑New Pump D Pump Replacement ❑Pump Repair ❑Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary 0 Air Rotary 4Auger ❑Cable Tool ❑Push Point ❑ Other <br /> Proposed Well Depth-G-50 ft Excavation in diameter ❑Open Bottom 0 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 ❑Stainless Steel ❑Other <br /> Grout Seal Depth ft Vd Neat Cement(94 Ib bag/5-10 gal water) ❑Sand Cement sack m/xl7 gal water <br /> D Bentonite(20%solids) ❑Other <br /> Grout Placement Method Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑Driller ❑Pump Contractor 0 Other <br /> ❑Concrete Pedestal DDimensions:Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe <br /> PUMP 0 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 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 /> INR 48H URA AN NCO E REQUIRED FOU INSPECT/IIgNS-IPLEASECALL(209)95 -7697 <br /> SIGNED TITLE l �l6 61 DATE Izl <br /> C% <br /> M,?018 <br /> CO <br /> A RN (Nry <br /> ,&A,/R M E N T U E O L <br /> Application Accepted By Date Area <br /> Employee ID# / <br /> Grout Inspection By Date W SPECIAL Well Permit <br /> Pump Inspection By Date 1 ❑ WAIVER Received <br /> Soil Boring Ins ection By • Date I Construeted ell epth <br /> COMMENTS Y �' UyblPTW1 ANSp <br /> PE Sc Received Check#/ Amount Date Permit/ Invoice# Well ID# ' I <br /> Codes Info Am Cash Remitted Service a uest# <br /> 21� <br /> EHD 43-06 reNsed 4114118 �T//��� /, WELL(PUMP PERMIT <br />