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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 /> JOB ADDRESS <br /> 6F CITYIZIP rfk Mra,0330 <br /> m <br /> D <br /> CROSS STREET APN PARCEL Stz:E�� LAND USE APPLICATION# an <br /> A <br /> Cy <br /> OWNER NAME � PHONE e! <br /> OWNER ADDRESS n yam^ CITY/STATE21P <br /> CONTRACTOR ►�1 ` r P NE�}`LJ ✓ <br /> CONTRACTOR ADDRESS 1 VRr , S&- OO CITYISTATE/7JP O V{S L <br /> SUBCONTRACTOR r • wry r� PHONE Aµ 2 O <br /> SUBCONTRACTOR ADDRESS u "r <br /> �C[-TYISTAa �� C5 311 <br /> LICENSE C-57 ❑C-61 ❑D-09 ❑Other NUMBER EXPIRATION DATE W <br /> DOMESTIC WELL SAMPLING:0 General Mineral/Coliform Bacteria(4391)0 Dibromochlor ropane(4392)0 Arsenic(4393) <br /> INTENDED USE ❑Domestic/Private ❑Irrigation/Agricultural ❑Industrial D Water Quail 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/Mod cati ❑Other <br /> ❑Monitoring Well(s) #of wells D Soil Borings) #of borings g(Geotechnical #of bodngs <br /> ❑Out-Of-Service Well ❑Out-Of-Service Well newal ❑Cross-Connection Repair <br /> ❑New Pump ❑Pump Replacement ❑Pump Repair D Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method 0 Mud ota ❑Air Rotary ¢Auger ❑Cable Tool ❑Push Point ❑ Other <br /> Proposed Well Depth ft Excavation in dia ter ❑Open Bottom ❑ ravel Pack/Gravel Size in diameter <br /> ❑Conductor Casing in diameter / Conduct Casing Depth <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Sched ❑Steel D Plastic Stainless Steel ❑Other <br /> Grout Seal Depth ft It Neat Cement(94 Ib b /5 10 gal wateO ❑Sa sack mixR gal water <br /> ❑Bentonite(20%solids) ❑Other <br /> Grout Placement Method j Pumped D Free Fall ❑Other ❑Retard / levator(name) <br /> PEDESTAL Installed By ❑Driller ❑Pump Contracto ❑ Other <br /> ❑Concrete Pedestal❑Dimensions:Width ft Length Thick in D Christy Box ❑Stove Pipe <br /> PUMP ❑Submersible Turbine ❑Other HP mp Set ft Standing Water Level ft <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS/APPLICATION AND T HE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS, D RULES AND REG ATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA ONTRACTORS ST E I ENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> NI UM R ADVANCE TICE REQU E F R INS TIQNS-PLEASE CALL(209) 53 6�9/7J7 <br /> SIGNED TITLE jN DATE I <br /> T <br /> D <br /> 9 <br /> A <br /> TY <br /> r <br /> DEJAWTMENT VSE ONLY �y����� <br /> Application Accepted By D to Area Employee ID#1 I//Nf F�/J <br /> Grout Inspection By Date ❑ SPECIAL ell Permit �''''--' <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> i <br /> PEC <br /> Received Check#/ Amount Permit/Code Info B Cash emitted Date rvice Re uest# Invoice# Well ID# <br /> EHD 43-06 revised 4/14/18 WELL/PUMP PERMIT <br />