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WELL/PUMP PERMIT <br /> SAN*OAQUIN 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 /> � <br /> JOB f.DDRESS CITY/ZIP ,Q am <br /> i t /J D <br /> CROSS STREET I- f 4 ll�aPN /x.52 j�/ O�l PARCEL SIZE � LAND USE APPLICATION#r / $� S <br /> OWNER NAME S� f ' J 1. 9/ /�/ C" / P O E J�O J f��QO N <br /> OWNER ADDRESS �% 3 s t�S 7[ d"V����(:ITY�TYITE/ZIP �O S <br /> CONTRACTOR jt ' ./t PHONE, b �S - L�2 f� <br /> n Q /�• I I//►� .r <br /> CONTRACTOR ADDRESS 3d'0 v. /1 i'/fvw t/ CITY/STATE/ZIP /�L eL C k <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> j <br /> LICENSE to"C-57 ❑ C-61 CI D-09 1 Other NUMBER ��3��) a EXPIRATION DATE-0 - <br /> DOMESTIC WELL SAMPLING: 1 1 General Mineral/Coliform Bacteria (4391) 1 Dibromochloropropane(4392) I Arsenic(4393) <br /> INTENDED USE omestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Char jpg <br /> ❑ Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Numbe / <br /> TYPE OF WORK New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other DFr <br /> ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings LI GeotechnicaLc..., d ° °?818 <br /> ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair A,DAQQN/N O N <br /> ❑ New Pum ❑ Pum Replacement ❑ Pum Repair ❑ Raise Well Casing / C U <br /> WELL CONSTRUCTION S/?T <br /> MFNT <br /> Drilling Method k<—ud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other <br /> Proposed Well Depth 2 00 ft Excavation �0%Yin diameter ❑ Open Bottom (WGravel Pack/Gravel Size in diameter <br /> ❑ Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter 6,.- in Thickness/Gauge/ASTM Sched 502 1 ❑ Steel AlKa-stic ❑ Stainless Steel ❑ Other <br /> Grout Seal Depth /4ib ft I I Neat Cement(94/b bag/5-10 gal water) CI Sand Cement sack mix17 gal water <br /> oft—entonite(20%solids) ❑ Other <br /> Grout Placement Method gimped ❑ Free Fall ❑ Other 11 Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller ump Contractor 1 Other <br /> Concrete Pedestal ❑Dimensions:Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe <br /> PUMP Submersible Cl 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 /> M IM OUR ADVANCE NOTICE REQUIRED FOR INSPECT}ONSS -PLEASE CALL (209) 953-7697 <br /> SIGNED TITLE�C,dyFtQ p�✓ DATE / 17 <br /> I <br /> 11 1 IT 14 H <br /> DEPARTMENT USE ONLY <br /> Application Accepted By ��/ Date z / ( Area Employee ID#A� <br /> Grout Inspection By Date [I SPECIAL Well Permit <br /> Pump Inspection By Date l] WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Chec Amount Date Permit/ Invoice# Well ID# <br /> Codes Jnfo 13yA ash Remitted Service Request# <br /> 10 3 II K <br /> EHD 43-06 6/01/16 WELL/PUMP PERMIT <br />