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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 /> \ JOB ADDRESS Z� L- CITY/ZIP 4' m <br /> ,rte y <br /> CROSS STREET C� APN �[J — D PARCEL SIZE LAND USE APPLICATION# S <br /> OWNER NAME P ! P ONE 1� y <br /> OWNER ADDRESS V L CITY/STATE/ZIP ✓f7v`r/ <br /> CONTRACTOR 1— `Wl 1 is 1 PHONE <br /> CONTRACTOR ADDRESSWA ci'r fCITY/STATE/ZIP <br /> SUBCONTRACTOR V('C_ 1I't Sst(rt7 <br /> PHONE <br /> SUBCONTRACTOR ADDRESS 19IIP1246 CITY/STATE/ZIPP /djq J 1 <br /> A <br /> LICENSE C-57 I I C-61 I1 D-09 ❑ Other NUMBER quXfd6o, EXPIRATION DATE <br /> DOMESTIC WELL SAMPLING: I I General Mineral/Coliform Bacteria(4391)❑ Dibromochloropropane(4392)Cl Arsenic(4393) <br /> INTENDED USE ?N Domestic/Private Irrigation/Agricultural i l Industrial 11 Water Quality Monitoring J Soil Sampling/Characterization <br /> I I Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK )4:New Well Replacement Well II Well Alteration/Modification ❑ Other <br /> (I Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings ❑ Geotechnical #° ie <br /> I i Out-Of-Service Well I I Out-Of-Service Well Renewal I I Cross-Connection Repair JUL 2 <br /> I I New Pum I Pum Replacement I I Pum Repair I 1 Raise Well Casing <br /> cc ,, U <br /> WELL CONSTRUCTION `"�>rY <br /> Drilling Method Mud Rotary LI Air Rotary J Auger Cl Cable Tool I Push Point I I Other ENV/ROV/N CONN <br /> Proposed Well Depth ft Excavation l vZV in diameter I I Open Bottom ❑ Gravel Pack/Gravel Size r e " fi4sh AW <br /> I 1 Conductor_Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter 6- in Thickness/Gauge/ASTM Sched ;20C> I I Steel A Plastic ❑ Stainless Steel 11 Other <br /> Grout Seal Depth 0'3 ft ❑ Neat Cement(94 lb bag/5-10 gal water) 1_I Sand Cement sack mix/7 gal water <br /> 4Bentonite(20%solids) I1 Other <br /> Grout Placement Method Pumped ❑ Free Fall ❑ Other 11 Retardant/Accelerator(name) <br /> PEDESTAL Installed By I I Driller 1'Pump Contractor Other <br /> I I Concrete Pedestal I(Dimensions:Width ft Length ft Thick in ❑ Christy Box I I Stove Pipe <br /> PUMP Submersiblel I Turbine I1 Other____L_ HP Pump Set ft Standing Water Level•Q _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 /> CURREN ND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKE S OMPENSATION LAWS. <br /> I I <br /> �ftCENQTICE REQUIRED FO NSPEC IONS -PLEASE CALL(209) 910-7697 <br /> SIGNED TITLE DATE <br /> �o (i <br /> r <br /> G ' O <br /> -97 0 11 <br /> v <br /> fi e <br /> DARTMENT U E qeNLY <br /> 10 —Z <br /> Application Accepted By Date Area Employee ID#� <br /> Grout Inspection By Date FI SPECIAL Well Permit <br /> Pump Inspection By Date FI WAIVER Received <br /> Soil Boring Inspection By Dale Constructed Well Depth ft <br /> COMMENTS i <br /> PE Sc Received Ch Amount Date Permit/ Invoice# Well ID# <br /> Codes Info Byn Cash Remitted Service Re uest# <br /> 0 -L9c, 9151A <br /> 0� <br /> EHD 43-06 8/01/16 WELL/PUMP PERMIT <br />