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t WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY Et-ARONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 <br /> NON-REFUNCABLE PERMIT CALL 09)953-7697 FOR INSPECTIONS E PIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS I CITY/ZIP C sf �r N <br /> M <br /> �J r D <br /> CROSS STREET 1 �t J� AP <br /> N b (/vPARCEL SIZE L_ LAND USE APPLICATION# , S <br /> >/ m <br /> OWNER NAME f P?HONE�vI\� j ff- .�JI�I/C� <br /> OWNER ADDRESS CITY/STATE/ZIP <br /> CONTRACTOR �I i7�F�iy✓�.^J ICC.(��j PHONE ��— <br /> CONTRACTOR ADDRESS / °� �,J CITY/STATE/ZIP <br /> SUBCONTRACTOR !` ;;' (J�w�C' �� /i�' PHONE? <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE C 57 ❑C 61 ❑D 09 ❑Other NUMBER ? � EXPIRATION DATE <br /> DOMESTIC WELL SAMPLING:❑General Mineral/Coliform Bacteria (4391)❑Dibromochloropropane (4392)❑Arsenic(4393) <br /> INTENDED USE Domestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization <br /> ❑Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number Iva <br /> TYPE OF WORK `Kilew Well ❑Replacement Well ❑Well Alteration/Modification ❑Other <br /> [-]Monitoring Well(s) #of wells ❑Soil Boring(s) #of boringsVP® <br /> L]Geotechnical <br /> F]Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair OcI <br /> New Pump ❑Pump Replacement ❑Pump Repair [_]Raise Well Casing <br /> WELL CONSTRUCTION JOA O <br /> Drilling Method a�Mud Rotary [-]Air Rotary ❑Auger ❑Cable Tool F]Push Point E] Other HFAN f/RR Co <br /> Drilling <br /> Proposed Well Depth�3w ft Excavation in diameter [-]Open Bottom Gravel Pack/Gravel Size ARLMr i eter <br /> ❑Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter:6_ in Thickness/Gauge/ASTM Sched[_ ❑Steel Xastic ❑Stainless Steel L]Other <br /> Grout Sea! DcrthVt)C; ft E]Neat Cement(94 ib bag/5-i0 gai water; `j�and Cement / z_j sack mix17 gal water <br /> E]Bentonite(20%solids) ❑Other <br /> Grout Placement Method,,<'umped ❑Free Fall ❑Other [_]Retardant/Accelerator(name) <br /> PEDESTAL Installed By >klbriller El Pump Contractor ❑ Other <br /> ❑Concrete Pedestal dimensions:Width ft Lengthft Thick in ❑Christy Box []Stove Pipe <br /> PUMP ubmersible❑Turbine ❑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-24 24 H U DVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-769(7 <br /> SIGNED �'�- ) / / ! j —�( ' <br /> /�� TITLE ` � CJCY� t DATE <br /> 0 <br /> J <br /> 1 <br /> \ A <br /> E ARTMENT <br /> U� E(,, NLY <br /> Application Accepted By Date V V Area Employee I D# N 1 <br /> Grout Inspection By - Date ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received j <br /> Soil Boring Inspection By Date �Constructed Well Depth ` ft <br /> COMMENTSTIZA7�/S � p�e <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info Cash �RguLJUPd Service Request# <br /> �172 IIS, I Eti M9 11 2-ft <br /> I 1v " .o <br /> v o <br /> EHD 43-06 8/01/16 WELL/PUMP PERMIT <br />