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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 /> JOB ADDRESS .�5 ►'1 , 1 � CITY/ZIP i-,-- `� /"/<J y m <br /> CROSS STREET Soh APN 31 1,9 PARCEL SIZE I LAND USE APPLICATION# <br /> OWNER NAMEJ,(�j�! C7 �PHONE <br /> OWNER ADDRESS �'/ ,'[ L`' CITY/STATE/ZIP I 6 v Qfl 2 <br /> CONTRACTOR TL4! �C7r1 /V I I I��0✓s Off') ( PHONE �y`� — 3 32� <br /> CONTRACTOR ADDRESSy!T�K �+57�lli �''� CITY/STATE/ZIP Z � � �y <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CI/TY/STATE/ZIP <br /> LICENSE C-57 ❑ C-61 ❑ D-09 ❑ Other NUMBER V CD� EXPIRATION DATE <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) 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 <br /> ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings 'Geotechnical_�#of borings <br /> ❑ 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 Amud Rotary ❑ Air Rotary Auger ❑ Cable Tool ❑ Push Point ❑ Other <br /> Proposed Well Depthft—S O ft Excavation in diameter I 1 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 Cl Steel ❑ Plastic ❑ Stainless Steel ❑ Other <br /> Grout Seal Depth ft XNeat Cement(94 Ib bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water <br /> ❑ Bentonite(20%solids) ❑ Other <br /> Grout Placement Method ❑ Pumped ❑ Free Fall XOther _Tre/rgrh,,f_ I I 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 /> MINIMUM 8 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS -PLEASE CALL (209) 953--7697 <br /> SIGNED , /)I/V✓ TITLE t�� S DATE <br /> c <br /> L <br /> HEAI_TH DPAT ET <br /> D — PARTMENT USE N L Y <br /> :I <br /> Application Accepted By ' Date - Area Employee ID# <br /> Grout Inspection By Date 2,[63 U SPECIAL Well Permit <br /> Pump Inspection By Date Ll WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Dept ft <br /> COMMENTS 'k <br /> PE Sc Received Check#/ Amount Permit/Codes Info B Cash emitte Date Service Request# Invoice# Well ID# <br /> EHD 43-06 8/01/16 WELL/PUMP PERMIT <br />