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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 /> r <br /> I ' /� �- CITY/ZIP C N <br /> JOB ADDRESS n m <br /> J Q Irl L D <br /> CROSS STREET c/ APNPARCEL SIZE`'V�t LAND USE APPLICATION# o <br /> m <br /> m <br /> OWNER NAME I^, PHONE (\ N <br /> OWNER ADDRESSLOU '� CITY/STATE/ZIPJq`� <br /> �/ <br /> CONTRACTOR P_HONNE :O GNU 13-7V ' <br /> ` r <br /> CONTRACTOR ADDRESS U Wei CITY/STATE/ZIP �°"N CI P��y � <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP (� G� <br /> LICENSE Ef C:-57 ElC-61 F-1 D-09 El Other NUMBER D J EXPIRATION DATE J / /�0 <br /> DOMESTIC WELL SAMPLING:❑General Mineral/Coliform Bacteria (4391)❑Dibromochloropropane (4392)❑Arsenic(4393) <br /> INTENDED USE ❑Domestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring 0'50-iI 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 #of borings <br /> eotechnical <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 E]Mud Rotary ❑Air Rotary Her ❑Cable Tool El Push Point ❑ Other <br /> Proposed Well Depth I S-S-D ft Excavation -(12 in diameter El Open Bottom [-]Gravel Pack/Gravel Size in diameter <br /> F]Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑Steel ❑Plastic El 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 ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑ Other <br /> E]Concrete Pedestal Epimensions:Width ft Length ft Thick in []ChristyBox ❑Stove Pipe <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 D ORNANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIV WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPEN ION LAWS. <br /> pUHOU�DV�A/CE NOTICE REQUIRED FOR IN SPE <br /> MCTIONS - PLEASE CALL (209) 953-7697/ u <br /> SIGNED ..�,�,_�J�,� �`�`� TITLE DATE <br /> a� <br /> DEPARTMENT USE ONLY' <br /> Application Accepted By Date �� Area Z__/;4-1 .V/Employee I ID# <br /> Grout Inspection By Date ❑ PECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection By�lSzlw � � Date /er��`/B' Constructed Well Depth ft <br /> COMMENTS <br /> PE SC ReceivedCheck#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B ash Remitted Service Request# <br /> EHD 43-06 8/01/16 WELL/PUMP PERMIT <br />