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" WELL/PUMP PERMIT <br /> .. f 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 ADDR(af -{ or, CITY/ZIP 11b —(J m <br /> D <br /> CROSS STREET VV 1I� S Pi V e, APN 1 1 I —O P CEL SIZE l O6.01 LAND USE APPLICATION# A <br /> OWNER NAME ' I� ys� ( /v`� PHONE ` m <br /> OWNERADDRESS CITY/STATE/ZIP <br /> CONTRACTOR PPHONE CtOl <br /> 94V <br /> 1 P_ <br /> 1341 <br /> CONTRACTOR ADDRESS 0 r G f►^ Ir� v ���I�UCITY/STATEIZIP ✓�Xhkh "13-tA <br /> SUBCONTRACTOR 11 ( PHONE /' <br /> (ZOO1 — 0 <br /> L <br /> SUBCONTRACTOR ADDRESS- LArS� Dr Cm (/�� <br /> /STATE/ZIP `moi Ct I)1 C 9SO Z <br /> LICENSE .j C.57 C C-61 ❑D-09 ❑Other NUMBER -/0 l EXPIRATION DATE <br /> DOMESTIC WELL SAMPLING:F1 General Mineral/Coliform Bacteria(4391)n Dibromochloropropane(4392)n Arsenic(4393) <br /> INTENDED USE 7 Domestic/Private ❑Irrigation/Agricultural C Industrial ❑Water Quality Monitoring t Soil Sampling/Characterization <br /> 7 Public Water System <br /> If different from Owner. Water System Name Contact Name or Phone Number <br /> TYPE OF WORK 7 New Well ❑Replacement Well C Well Alteration/Modification ]Other <br /> 7 Monitoring Well(s) #of wells C Soil Boring(s) #of borings 4Geotechnical 11 borings <br /> 3 Out-Of-Service Well C Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> -1 New Pum -1 Pump Replacement n Pump Repair n Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method.71 Mud Rotary n Air Rotary IjAuger n Cable Tool -1 Push Point n Other_ <br /> Proposed Well Deptt}�"So It Excavation in diameter L Open Bottom L Gravel Pack/Gravel Size t r <br /> D Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Schad C Steel C Plastic 7 Stainless Steel 7 Other <br /> Grout Seal Depth ft 4Neat Cement(94 Ib bag15-10 gal water) C Sand Cement sack ��er <br /> Bentonite(20%solids) ❑Other <br /> Grout Placement Method J Pumped 7 Free Fall 7 Other 7 Retardant/Accelerator(name) 0129 <br /> PEDESTAL Installed By I I Driller I Pump Contractor I Other <br /> D Concrete Pedestal❑Dimensions:Width it Length It Thick in ❑Christy Box ❑ �Nry <br /> PUMP -1 Submersiblen Turbine n Other HP Pump Set ft Standing Water Level ft EST <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 4A HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)[9 3-7 97 <br /> SIGNED W`" TITLE �J fir EJ'IQt`YIeAQr DATE 6JIUM <br /> "F,PMENT U E O LYApplication Accepted ByDate Area s� Employee ID#Grout Inspection ByDate ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#/ Amount Permit/ <br /> Codes Info B Cash Remitted Date Service Re uest# Invoice# Well ID# <br /> EHD 43-06 revised 4/14118 q�'/�Q�� WELL/PUMP PERMIT <br />