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WELL/PUMP PERMIT <br /> r SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)465-3420 <br /> NON-REFUNDABLE RMT CALL O 953-7697 FOR INSPECTIONS PIRES 1 FROM AUISSUED <br /> Gu <br /> JOB ADDRESS CITY/7jP m <br /> D <br /> 0 <br /> CROSS STREET APN PARCEL SIZE AND USE APPLICATION# z <br /> OWNER NAME <br /> ra PHO <br /> OWNER ADDRESS CITY/ST E <br /> CONTRACTOR A <br /> CONTRACTOR ADDRESS q <br /> V✓ CITY/STATE/ 0 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS 77CITY/STATE/ZIP <br /> LICENSE C-57 C-61 D-09 Other NUMBEfF ]I& _EXPIRATION DATE <br /> DOMESTIC WELLS PLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE V Domestic/Private 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 Other <br /> MonitoringWell(s) #of wells SoilBoring(s) 4ofborings Geotechnical #of borings <br /> Out-Of-Service WellOf-Service Well Renewal Cross-Connection Repair <br /> New Pump Pump Replacement ump Repair Raise Well Casino . <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary Air Rotary Auger Cable Tool Push Point 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 Schad Steel Plastic Stainless Steel Other <br /> Grout Seal Depth ft Neat Cement(941b 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 Retardant I Accelerator(name) �1 <br /> PEDESTAL Installed By Driller Pump Contractor Other -1 <br /> oncrete Pedestal Dimensions:Width ft Le h ft Thi in .Christy Box Stove Pipe W <br /> PUMP Submersible Turbine Other HP Pump Set V V 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 O INANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND AC WI HE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMP S WS. <br /> MINI 4 H UR ADVANCE NOTICE REQUIRED FOIR IINSPEC�1TIIO�NS�y-PLEA�j CALL(209 �5 <br /> SIGNED TD-LE / • a•V"a• 4 w DATE <br /> LU LU <br /> p = U <br /> N 5 <br /> W w <br /> w � <br /> o c`z <br /> XL <br /> CL <br /> Ip <br /> 11 1 7-1il VAIN <br /> PAYE V <br /> REC <br /> DEC III I T 71 LL- <br /> PA MENT US ON Y <br /> li r <br /> on Accepted By ate <br /> �OAQUIN%PIL GG tlut Inspection By Date Area Employee VPEOCIAL Well Permit D# <br /> c' 'EH pip TME p Inspection By ` Date WAIVER Received <br /> Soil Boring Inspection By Date�'���T�� Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Amount Permit/ <br /> Co s Info B Cash emitted Date Service Request <br /> # Invoice# Well ID# <br /> 2r <br /> EHD 43-06 8101116 WELL/PUMP PERMIT <br />