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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 `` / +L� /f./ CITY/ZIP E� ( V m <br /> c D <br /> CROSS STREET J l / �N� / O ARCEL SIZE LAND USE APPLICATION# A <br /> OWNER NAME � /�f/�✓��� PHONE to <br /> OWNER ADDRESS CITY/STATE/ZIP <br /> CONTRACTORS / I//� I`'�/� �/ '��1� cii"'/ ( PHONE <br /> CONTRACTOR ADDRESS f �� !i)(`!C �� / CITY/STATE/ZIP <br /> SUBCONTRACTOR /i� �� �G��//Ej PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE VC-57 0-61 ❑ D-09 ii Other NUMBER �Frl,6 EXPIRATION DATE <br /> DOMESTIC WELL SAMPLING: i General Mineral/Coliform Bacteria (4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE ,bomestic/Private (rrigation/Agricultural ❑ Industrial .1 Water Quality Monitoring [I Soil Sampling/Ch �r <br /> 11 Public Water Systteem <br /> If different from Owner: Water System Name Contact Name or Phone Num <br /> TYPE OF WORK ,lew Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other <br /> 1-1 Monitoring Well(s) #of wells Ll Soil Boring #of borings oors) ❑ Geotechnical <br /> ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal Cl Cross-Connection Repair "JORQUIN COUNTY <br /> -AAew Pum F1 Pump Replacement [I Pump Repair 11 Raise Well CasingH ONMENTAL <br /> WELL CONS'TR CTION ENT <br /> Drilling Method)&ud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool 1-1 Push Point ❑ Other <br /> Proposed Well Depth_ Excavation in diameter CI Open Bottom ravel Pack/Gravel Size ` in diameter <br /> ❑ Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter tv in Thickness/Gauge/ASTM Sched 1--014- n Steel '0lastic ❑ Stainless Steel ❑ Other <br /> Grout Seal DepthAV ft ❑ Neat Cement(94 Ib bag/5-10 gat water) ❑ Sand Cement sack mix/7 gal water <br /> JOentonite(20%solids) ❑ Other <br /> Grout Placement Method umped I1 Free Fall ❑ Other 11 Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller . ump Contractor ❑ Other <br /> 0 Concrete Pedestal ❑ Imensions:Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe <br /> PUMP ubmersible Fj Turbine [I Other HP Pump Set / Standing Water Level -t <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 /> MIN MCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-;697 <br /> SIGNED TITLE '�/r/% /`"`'` DATE <br /> 161 <br /> 10, <br /> Et RTMEfr U " c vf3LY <br /> Application Accepted ByAP-1 jDate l Area Employee ID#� <br /> Grout Inspection By Date -t 'a q Lo-L <br /> �� ❑ SPECIAL Well Permit <br /> Pump Inspection By `ML•�(fit ,,v.c PSL Date t I � ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> e CA <br /> PE SC Received Che Amount Permit/ <br /> Codes Info B Cash Remitted Date Service Request# Invoice# Well ID# <br /> S 0y <br /> 2<3 fT <br /> 3 I <br /> EHD 43-06 8/01/16 WELL/PUMP PERMIT <br />