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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 /> L � ~. � � ,!�i7/" CITY/ZIP <br /> Z m <br /> JOB ADDRESS G��� �i m <br /> 4 D <br /> CROSS STREET L-9 APN PARCEL SIZE `/ LAND USE APPLICATION# 0 <br /> OWNER NAME f�� L J PHONE - 061 � � <br /> ' <br /> OWNER ADDRESS %t CIS <br /> TY/STATE/ZIP <br /> CONTRACTOR I/4✓ PHONE �/ <br /> CONTRACTOR ADDRESS AL) A CITY/STATE/ZIP �� �rG.:✓!=l � <br /> SUBCONTRACTORr-K �c� � PHONE ca 1 l 4G1 <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> �9 <br /> LICENSE X�-57 1.1 C-61 ❑ D-09 _i Other NUMBER �i�' EXPIRATION DATE ^� G <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic(4393) <br /> INTENDED USE Domestic/Private Li Irrigation/Agricultural L I Industrial i I Water Quality Monitoring I I 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 IJ Replacement Well ❑ Well Alteration/Modification ❑ Other <br /> I 1 Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings Geotechnical #of borings <br /> L] Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> ew Pum 1-1 Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRU TION <br /> Drilling Methodt�ud Rotary 1 1 Air Rotary ❑ Auger LI Cable Tool I I Push Point CI Other <br /> Proposed Well Depth a <0 <br /> ft Excavation C �— in diameter I I Open Bottom Gravel Pack/Gravel Size in diameter <br /> !I Conductor Casing _in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched—2-07) f I Steel XPlastic i I Stainless Steel LI Other <br /> Grout Seal Depth i.30 ft ❑ Neat Cement(94 Ib bag/5-10 gal water) and Cement ;�. S sack mix17 gal water <br /> 1 1 Bentonite(20%solids) ❑ Other <br /> Grout Placement Method Pumped 1-1 Free Fall I I Other I Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller (I Pump Contractor,, ❑ Other <br /> Concrete Pedestal f]Dimensions:Width ft Length ft Thick ) n Christy Box Li Stove Pipe <br /> PUMP •f!!�Submersible I I Turbine I I 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 48 HOUR VANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br /> f <br /> SIGNED !` -/C „ W� TITLE � G�/�ri+it- DATE L�a— �I' rT <br /> G <br /> w. <br /> s <br /> N <br /> N / <br /> _ArA <br /> fW Tr <br /> .) �, 4- <br /> EPARTMENT US ONLY <br /> Application Accepted By Date Area Employee ID# <br /> Grout Inspection By Date CI SPEC AL Well Permit <br /> Pump Inspection By JS W If <br /> r .�, Date 4 i/wla, WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE Sc ReceivedAQWWPAmount Date Permit/ invoice# Well ID# <br /> Code# Info B Cash Remitted Service Request# <br /> 1o FrOS <br /> 7U <br /> EHD 43-06 8/01/16 WELL/PUMP PERMIT <br />