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1 <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 <br /> JOB ADDRESS S <br /> �(� CITY/ZIP [S In <br /> CROSS STREET APN I G, A.5J00 5 PARCEL SIZE _LAND USE APPLICATION# ' <br /> OWNER NAME ` PHONE <br /> OWNER ADDRESS � V[��r CIN/STATE/7i /� '[�J�f <br /> CONTRACTOR yj' ei�^ L [[�� 1 PHONE/ .,11 •�,7L1s <br /> CONTRACTOR ADDRESS 1..1 Aril.' e rr 1�0 R� ,p0 CITY/STATE21P \y' <br /> SUBCONTRACTOR ��r�l�t•[A� {,. ^ PHONE�_G► Q���_Z�O <br /> IV <br /> SUBCONTRACTOR ADDRESS 3Jo QtAf% Crag 1/h CITYISTATE/ZIP �'�6(r t / Q [�1I- <br /> LICENSE 117 f.:-57 D C-61 C D-09 ❑Other NUMBER EXPIRATION DATE `- <br /> DOMESTIC WELL SAMPLING:❑General Mineral/Coliform Bacteria(4391)C Dibromochloropropane(4392)C Arsenic(4393) <br /> INTENDED USE D Domestic/Private D Irrigation/Agricultural C Industrial D Water Quality Monitoring WSoil 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 7 Replacement Well D Well Alteration/Modification C Other <br /> ❑Monitoring Well(s) #of wells C Soil Boring(s) #°fb°rings Geotechnical f of borings <br /> D Out-Of-Service Well �]Out-Of-Service Well Renewal D Cross-Connection Repair <br /> D New Pump C Pump Replacement -1 Pump Repair C Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method v4d Rotary C Air Rotary 5KAuger C Cable Tool C Push Point C Other <br /> Proposed Well Depthq*-�ja_ft Excavation in diameter 7 Open Bottom D Gravel Pack/Gravel Size in diameter <br /> C Conductor Casing in diameter / Conductor Casing Depth It <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Schad Steel -i Plastic u Stainless Steel u Other <br /> Grout Seal Depth ft PAeat Cement(94 Ib bag/5-10 gal water) 7 Sand Cement sack mix/7 gal water <br /> i Bentonite(20%solids) I Other <br /> Grout Placement Method gimped C Free Fall C Other C Retardant/Accelerator(name) <br /> PEDESTAL Installed By 7 Driller D Pump Contractor �l Other <br /> n Concrete Pedestal nDimensions:Width It Length ft Thick in F Christy Box F Stove Pipe <br /> PUMP C Submersible 7 Turbine 7 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 4 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED 4 TITLE DATE 1AIS. q <br /> o <br /> Aki <br /> -019 <br /> OU <br /> FNT <br /> A%F MENT U E N <br /> il <br /> Application Accepted By 491&' to Area Employee ID#,� <br /> Grout Inspection By Date SPECIAL Well Permit <br /> Pump Inspection By Date C WAIVER Received <br /> Soil Boring Inspection By - Date Constructed Well Depth ft <br /> COMMENTS <br /> PE Sc Received Check#/ Amount Permit/ <br /> r.odes Info By Cash Remiged, Date 1501?ervic Re pest# Invoice# Well ID# <br /> 5 <br /> EHD 43-06 revised 4/14/18 q q 28 L 4 7 WELL/PUMP PERMIT <br />