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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 /> Ln <br /> JOB ADDRESS <br /> �l/ � L � CITY/ZIP (-,) r� � m <br /> CROSS STREET �l`—� APN ( � �-�a— `� PARCEL SIZELAND USE APPLICATION# <br /> rn <br /> OWNER NAME 7U -A I J PHO�qNE rn <br /> OWNER ADDRESS /'Y�✓4 D CITY/STATE/ZIP <br /> 11�� 1 <br /> CONTRACTOR - /r—� l ..ZS�S7 zL'Z V PHONE <br /> CONTRACTOR ADDRESS EG D /f3EECC��' CITY/STATE/ZIP exid '-),�w <br /> ^Z7 7 <br /> SUBCONTRACTOR g1 rJ7 PHONE , l <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE -57 ❑C-61 F1 D-09 Ll Other NUMBER �.Vf' EXPIRATION DATE {o" <br /> DOMESTIC WELL SAMPLING:❑General Mineral/Coliform Bacteria (4391)❑Dibromochloropropane (4392)❑Arsenic (4393) <br /> INTENDED USE ❑Domestic/Private Irrigation/Agricultural ❑Industrial [-]Water Quality Monitoring E]Soil Sampling/Characterization <br /> [-]Public Water System <br /> If different from Owner Water System Name L;ontact Name or Phone Number <br /> TYPE OF WORK �Vew Well ❑Replacement Well ❑Well Alteration/Modification F1 Other <br /> [-]Monitoring Well(s) #of wells ❑Soil Boring(s) #of borings ❑Geotechnical #of borings <br /> [j Out-Of-Service Well L]Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> ,grWew Pump Ej Pump Replacement El Pump Repair ❑Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method6tfMud Rotary ❑Air Rotary ❑Auger ❑Cable Tool E]Push Point ❑ Other <br /> Proposed Well Depth ft Excavation in diameter [-]OpenBottom Gravel Pack/Gravel Size in diameter <br /> ❑Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter C? in Thickness/Gauge/ASTM Sched.���vfi [_]Steel astic ❑Stainlless Steel ❑Other <br /> Grout Seal Depth SO, ft ❑Neat Cement(94 lb bag/5-10 gal water) 15�6and Cement /J 3 sack mix/7 gal water <br /> ❑Bentonite(20%solids) ❑Other <br /> Grout Placement Method�Pumped ❑Free Fall ❑Other [:)Retardant/Accelerator(name) <br /> PEDESTAL Installed By >jtriller ❑Pump Contractor ❑ Other <br /> ❑Concrete Pedestal dimensions:Width 4==ft Length ft Thick in ❑Christy Box [-]StovePi <br /> PUMP gi Submersible❑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 /> MINO/IUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br /> SIGNED .Gc TITLE (w"yA- DATE <br /> 1 <br /> r� <br /> P � fit' <br /> E P R T M E N T U7SE N L Y <br /> j�Application Accepted By Date Area Employee ID#62G 0 <br /> Grout Inspection Bynn �' + Date ❑ SPECIAL Well Permit <br /> Pump Inspection By AIM Date �I(l j ❑ WAIVER Received <br /> Soil Boring Inspection Byff Date Constructed Well Depth ft <br /> COMMENTS in ':byt(' <br /> i• <br /> PE SC Received hec Amount Date Permit/ Invoice# Well ID# <br /> Codes Info s Remitted Service Request# <br /> It 3 <br /> 7-7 C <br /> ETD 43-06 8/01/16 WELL/PUMP PERMIT <br />