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j sI�f <br /> 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 /> t raLn <br /> JOB ADDRESS ,./ CITYI7JP 1.4m <br /> / � C D <br /> CROSS STREET U r O APN S PARCELSIZE LAND USE APPLICATION# o <br /> z <br /> m <br /> OWNER NAME PHONE N <br /> OWNER ADDRESS p CITY/STATE2IP I/ <br /> 4-I h / L r <br /> CONTRACTOR PHONE / Q <br /> CONTRACTOR ADDRESS OI r �J�!_A 1 Pj bL/©0CITYISTATE/L `P ✓ `H ( 106 l <br /> SUBCONTRACTOR �( I Co PC,/PHONE 0 (�(_{(1`, V <br /> SUBCONTRACTOR ADDRESS �'p P-�L�r )1 CIN/STATEIZIP 1 I 136 <br /> LICENSE i C-57 ❑C-61 ❑D-09 ❑Other NUMBER 1�66 EXPIRATION DATE qj�1jDZ-0jj <br /> DOMESTIC WELL SAMPLING:0 General Mineral/Coliform Bacteria(4391)0 Dibrcmochloropropane(4392)❑Arsenic(4393) <br /> INTENDED USE 0 Domesfic/Private 0 Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring Soil Sampling/Characterization <br /> D Public Water System <br /> If different from Owner. Water System Name Contact Name or Phone Number <br /> TYPE OF WORK 0 New Well ❑Replacement Well ❑Well Alteration/Modification ❑Other <br /> 0 Monitoring Well(s) #of wells 0 Soil Borings) #of borings 9(Geotechnical�_�of borings <br /> 0 Out-Of-Service Well ❑Out-Of-Service Well Renewal 0 Cross-Connection Repair <br /> ❑New Pump ❑Pump Replacement ❑Pump Repair 0 Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method if Mud Rotary'�a0 Air Rotary it Auger 0 Cable Tool D Push Point ❑ Other <br /> ta <br /> Proposed Well Depth 7V ft Excavation in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter <br /> ❑Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Schad ❑Steel 0 Plastic 0 Stainless Steel 0 Other <br /> Grout Seal Depth ft d Neat Cement(941b bag/5-10 gal water) 0 Sand Cement sack mixf7 gal water <br /> ❑Bentonite(20%solids) 0 Other <br /> Grout Placement Method [(Pumped 0 Free Fall 0 Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By 0 Driller 0 Pump Contractor 0 Other <br /> ❑Concrete Pedestal❑Dimensions:Width ft Length ft Thick in ❑Christy Box 0 Stove Pipe <br /> PUMP ❑SubmersibleD Turbine ❑Other HP Pump Set It 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 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> M IM M 4 UR ADVANCE NOTICE REQUIRED FORINS TIOPIS-PLEASE CALL(209) -7697 <br /> SIGNED TITLE ✓ �Q ` C�/T<' DATE <br /> UARTMENT � E Q LY <br /> Application Accepted By Date ! Area ployee ID# <br /> Grout Inspection By Date 2 ❑ PECIAL WBII Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection By Date Construct d WeIL Depth ft <br /> COMMENTS <br /> -pAyMENT <br /> PE SC Received Check#/ Amount Date permit/ Invoice# Well 1 E�tl ED <br /> Codes Info B Cash Remitted Service Re uest# <br /> i A 3 1 2®i9 <br /> QUIN COUNT'( <br /> SAN je <br /> ONMENTAL <br /> EHD 43-06 revised 4/14/18wELLrPUMP p�LTH DEPARTMENT <br />