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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 'C,ALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FR9,M DATISSUED <br /> JOB ADDRESS <br /> L�� l r r CITY/ZIP C ti��� C �r►7 rJ� m <br /> m <br /> CROSS STREET L��. O 'V ,,�� PN 00'_� PARCEL SIZE LAND USE APPLICATION# o <br /> In <br /> OWNER NAME \ PHONE N <br /> OWNER ADDRESS CITY/STATE/ZIP ^ q _ <br /> CONTRACTOR AI PHONE�I c <br /> CONTRACTOR ADDRESS ��_/ (/X `�� y� CITY/STATE/ZIP_('11'j U N <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS ��jjCITY/STATE/ZIP <br /> LICENSE C-57 ❑C-61 El D-09 E]Other NUMBER�J�� EXPIRATION DATE(' <br /> DOMESTIC WELL SAMPLING:JaGeneral Mineral/Coliform Bacteria (4391)❑Dibromochloropropane(4392)❑Arsenic(4393) <br /> INTENDED USE kbomestic/Private atiea/4grieLiFtdrai ❑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 XNew Well ❑Replacement Well ❑Well Alteration/Modification ❑Other <br /> ❑Monitoring Well(s) #of wells ❑Soil Boring(s) #of borings #of borings <br /> ❑Geotechnical <br /> F1 Out-Of-Service Well E]Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> New Pump ❑Pump Replacement ❑Pump Repair ❑Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method ❑Mud tary E]Air Rotary ❑Auger able Tool ❑Push Point ❑ Other <br /> Proposed Well Depth 600 It Excavation in diameter Open Bottom ❑Gravel Pack/Gravel Size in diameter <br /> ❑ConductCasing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter 6 in Thickness/Gauge/ASTM Sched J_�_!� Steel ❑Plastic ❑Stainless�Steel E]Other <br /> Grout Seal Depthi_ft ❑Neat Cement(94 lb bag/5-10 gal water) XSand Cement ( 1/, 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 /> E]Concrete Pedestal❑Nmensions:Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe <br /> PUMP 1�6ubmersible❑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 /> MINIMU OUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br /> SIGNED o TITLE KAiZJj t^_rD i Z DATE <br /> 1 <br /> z <br /> C I <br /> C' <br /> W <br /> J <br /> _I <br /> L') <br /> i <br /> DEARTMENW/�v <br /> N L Y <br /> Application Accepted B DateAreakl qI Employee ID#��'r0 <br /> Grout Inspection By �Q2i1� , Date ❑ PECIAL Well Permit <br /> Pump Inspection By Date 0 WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth J p ft <br /> COMMENTS <br /> PE Sc Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes, Info By Cash Remitted i Service Request# <br /> r 3 , -7— i <br /> o 7-IS7A3 <br /> S� <br /> EHD 43-06 8/01/16 WELL/PUMP PERMIT <br />