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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-REFUNDAB P MIT CALL/2y0'�9 A95y3'�-76 7 FOR INSPECTIONS EXPIR S 1 YE /FROM DATE ISSUED <br /> JOB ADDRESS f r l 1/ I til CtTY/ZI a y <br /> m <br /> CROSS STREET 'l N I`fl P PN I �[� PARCJE/L SIZE{y• AND US A PPPUCATION# O <br /> OWNER NAME V `� /J ✓ HONE r w <br /> 7 /, 1 - <br /> OWNER ADDRESS L // VL ILA <br /> /) A(7 W a CITY TA E/ZIP Tq <br /> N <br /> CONTRACTOR t CA IL l/� ' PHONE0 <br /> CONTRACTOR ADDR_E$S 'y11 CITY/S A E IP <br /> SUBCONTRACTOR N PHONE. <br /> SUBCONTRACTOR ADDRESS / IT^Y`/STATE�/^1VVZIIPP 1 <br /> LICENSE C-57 C-61 D-09 Other NUMBER •t t[' E%PIRATON DATE 12, <br /> DOMESTIC WELLS PILING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE VDomesticlPrivate 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 /> Monitoring Well(s) #of wells Soil Boring(s) #of bongs Geotechnical #of borings <br /> Out-Of-Servioy Vj�ell - Out-Of-Service Well Renewal Cross-Connection Repair <br /> New Pum y Pum Replacement - Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drill'ng 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 Sched 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 T <br /> Grout Placement Method Pumped Free Fall Other Retardant/Accelerator(name) `I <br /> PEDESTAL Installed By Driller Pump Contractor Other <br /> oncrete Pedestal Dimensions:Width ft Length ft Thick in c Christy Box ove Pipe <br /> PUMPV Submersible Turbine Other HP Pump Se 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 ANDTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COM TION LAWS. <br /> MIN 24 HOUR ADVANCE NOTICE REQUIRED FOR IPECTIONNS-PLEASE CALL(209) <br /> SIGNED 1A i TITLE U'• / 1la (/ DATE `$5 �p <br /> / <br /> PAYME .n <br /> RECE►V .>S <br /> 1u�- 13 <br /> SANJOAnUiN U <br /> EtdVIRONM N <br /> HEAILTFI pEP <br /> D "P RTMENT USE NLY <br /> Application Accepted By Date �2' Area �(� Employee ID# <br /> Grout Inspection By Date 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 C Amount Date Permit/ Invoice# Well ID# <br /> Cods Info B Cash Remitted Service a uest# <br /> EHD 43-06 ai01116 <br /> WELL/PUMP PERMIT <br />