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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-REF N ABA1LE PERMIT CALL 209{ 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> +JOB ADDRESS IV+ ""q r 1 CITY/ZIP LSI'' m <br /> loam ��_ - moo— n <br /> CROSS STREET /�yca� APN Q L40 ' �Y PARCEL SIZE 0 LAND USE APPLICATIONx# 0 <br /> OWNER NAME m �l l S CO /ACI -r PHONE �3 <br /> yr <br /> OWNER ADDRESS �l \ (:ITY/ TATE/ZIP O , <br /> CONTRACTOR N U1 l- rrA cey-,> PHONE U l L, 3 V <br /> CONTRACTOR ADDRESS - I r{'1)= —F--Kd,,cs4--yi tS u CITY/STATE/ZIP La Ci; <br /> T <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE C-57 11 C-61 C-61 D-09 Other NUMBER \ EXPIRATION DAT <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) I I 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 [I Mud Rotp 11 Air Rotary 1YAuger ❑ Cable Tool ❑ Push Point ❑ Other <br /> Proposed Well Depth_ Kft 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 eat 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 ❑ Other M 1 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 OMPENSATION LAWS. <br /> MUM 8 H R A VANCE NOTICE REQUIRED FOR/I�P,1ECTI'OON'S,-�P'LEASE CALL (2091) 953--7697 <br /> SIGNED CJ - TITLE `� �E�k!S� DATE <br /> �� :. <br /> m - <br /> All 0, <br /> M <br /> UA TVA <br /> DEP RTM ENT USE <br /> L ONLY <br /> Application Accepted By Date o3 AreaEmployee ID# <br /> Grout Inspection By Date I I L, SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth CSX ft <br /> COMMENTS <br /> PE SC Received Ch Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B Cash Remitted Service Request# <br /> EHD 43-06 8/01/16 WELL/PUMP PERMIT <br />