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10 WELL/PUMP PERMIT <br /> S„N 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 /> JOB ADDRESS ' rJ p r. CITYIZIP h m <br /> �/ s / ,f� �J/ D <br /> CROSS STREET V V 01 Gtr/ !-!! yA�P/N�IJQ ✓�O �V PARCEL SIZED. b LAND USE APPLICATION# A <br /> OWNER NAME OV'(A/G J &S•• PHONE y <br /> OWNER ADDRESS W5,-i J CITY/STATE/ZIP y�p -- / <br /> CONTRACTOR �2��H Ll?I/1 V l'1 �• AQe-<SD✓1 PHONE 201 30- 3/701 <br /> CONTRACTOR ADDRESS-12).- Lln� hs�✓i h' �'� CITY/STATE/ZIP'�b� �7! 1951 yc <br /> SUBCONTRACTOR (T� PHONE <br /> SUBCONTRACTOR ADDRESS CITY/ST <br /> `A <br /> 'TE/ZIP 2 ) r <br /> LICENSE )(C-57 El C-61 El D-09 Li Other NUMBER�i ivy(/o� EXPIRATION DATE_� •J ''- /Gl <br /> DOMESTIC WELL SAMPLING: n General Mineral/Coliform Bacteria (4391) 1 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 Numb bA <br /> TYPE OF WORK ❑ New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other <br /> ❑ Monitoring Well(s) #of wells KSoil Boring(s) #of borings ❑ Geotechnical FXr1D <br /> ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> 11 New Pum ❑ Pum Replacement ❑ Pum Repair ❑ Raise Well CasingFEBF'F 0 <br /> WELL CONSTRUCTION SAN JOAQUIN CO <br /> Drilling Method Mud Rotary El Air Rotary X Auger ❑ Cable Tool ❑ Push Point 11 Other ENVIROfvAA UNTY <br /> < <br /> Proposed Well Depth�(�ft Excavation in diameter ❑ Open Bottom El Gravel Pack/Gravel Size H DEPARTS e et r <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 1['31 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 /> PUMP ❑ Submersible❑ Turbine r_l 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 /> MINIMUM 478�HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 9/53-7697 <br /> SIGNED�� f TITLE 6 e0b6jj t DATE <br /> Fr <br /> DEP RETMENT U NLY <br /> Application Accepted By Date Area Employee ID# <br /> Grout Inspection By Date D SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> 111 <br /> Soil Boring Inspection By � Vli`�/ Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Amount Permit/Codes Info B Cash emitte Date Service Request# Invoice# Well ID# <br /> EHD 43-06 8/01/16 WELL/PUMP PERMIT <br />