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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 2 953-7697 FOR INSPECTIONS XPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS CITY/ZIP m <br /> CROSS STREETAPN O 0" ODS / <br /> PARCEL SIZE LAND USE APPLICATION# o� <br /> IL <br /> � En <br /> /`�� m <br /> OWNER NAME PHONE L Cn <br /> OWNER ADDRESS CITY/STATE/ZIP I <br /> CONTRACTOR b/A` 1 L ONE�I I <br /> CONTRACTOR ADDRESS 6 CITY/STATE/ZIP j <br /> SUBCONTRACTOR 0 M PHONE <br /> SUBCONTRAC R ADDRESS 1 / TATE/ZIP <br /> LICENSE !C-57 ❑C-61 ❑D-09 ❑Other NUMBER EXPIRATION DATE <br /> DOMESTIC ELL MPLING:[-]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 E]Other <br /> ❑Monitoring Well(s) #of wells ❑Soil Boring(s) #of borings ❑Geotechnical #of borings <br /> ❑Out-Of-Service ell [:]Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> ❑New Pum Pump Replacement ❑Pump Repair ❑Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method E]Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool F1 Push Point ❑ Other <br /> Proposed Well Depth ft Excavation in diameter L)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 El Stainless Steel E]Other <br /> Grout Seal Depth ft ❑Neat 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 ❑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 /> 9 109 <br /> PUMP Submersible❑Turbine ❑Other HP Pump Set ft Standing Water Level ft <br /> 1 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 IMUM 4 UR DVANCE NOTICE REQUIRED FOR INSPE TIONS - PLEASE CALL (209) 953-76 <br /> SIGNED �' TIT E�DATE <br /> H AQ F <br /> of F <br /> Ft t <br /> DLA RTMENT US ONLY <br /> Application Accepted By Date Area Employee ID#�:�� <br /> Grout Inspection B Date ❑ SPECIAL Well Permit <br /> Pump Inspection B Date WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Che Amount Date Permit/ Invoice# Well ID# <br /> Codes Info ash Remitted Service Request# <br /> &- "7 L-1 <br /> EHD 43-06 6/01/16 WELL/PUMP PERMIT <br />