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*. WELL/PUMP PERMIT P <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 /> LP <br /> .JOB ADDRESS s CITY/ZIP m <br /> CROSS STREET C-�Z- APN V7���6✓� PARCEL SIZE LAND USE APPLICATIO # A <br /> cn <br /> m <br /> OWNER NAME �!'i7 HONE V✓� + �/N' cn <br /> OWNER ADDRESS CITY/STATE/ZIP <br /> CONTRACTOR .—EVIL) PHONE 6"93 �_15lam/l/ <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> SUBCONTRACTOR A Al PHONE <br /> /y /–A- — —7 <br /> SUBCONTRACT R ADDRESS CIT /STATE/ZIP <br /> LICENSE C-57 ❑ C-61 ❑ D-09 ❑ Other NUMBER EXPIRATION DATE <br /> DOMESTIC PELL SAMPLING: _i General Mineral/Coliform Bacteria (4391) Dibromochloropropane(4392) 1 1 Arsenic(4393) <br /> INTENDED USE 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 kA <br /> ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings ❑ Geotechnical MR s <br /> ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair �A <br /> Li New Pum Pum Replacement Ll Pump Repair F1 Raise Well CasingM <br /> WELL CONSTRUCTION <br /> Drilling Method ❑ Mud Rotary EI Air Rotary ❑ Auger F1 Cable Tool Ll Push Point El Other SAN ft?N1j1N <br /> Proposed Well Depth ft Excavation in diameter I I Open Bottom ❑ Gravel Pack/Gravel &T liWameter <br /> ❑ Conductor Casing in diameter / Conductor Casing Depth ft MENT <br /> Well Casing Diameter_ in Thickness/Gauge/ASTM Sched 11 Steel ❑ Plastic ❑ Stainless Steel ❑ Other <br /> Grout Seal Depth ft ❑ Neat Cement(94 lb bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water <br /> ❑ Bentonite(20%solids) ❑ Other <br /> Grout Placement Method LI Pumped ❑ Free Fall ❑ Other CI 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 ❑ 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 /> I 2 rMDVC OT CE REQUIRED F �tn <br /> S -PLEASE CALL (20%99 - 97 <br /> SIGNED TITLE DATE <br /> J <br /> PARTM ENT USE ON ('Q3 �9 <br /> Application Accepted By Date Area Employee ID# <br /> Grout Inspection By Date I ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received ec Amount D e Permit/ Invoice# Well ID# <br /> Code Info B ash Remitted Service Request# <br /> Ml pmo?ac t.0 <br /> EHD 43-06 8/01116 WELL/PUMP PERMIT <br />