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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 / / /1✓ CITY/ZIP m <br /> D <br /> CROSS STREET l� N, ) O 6&ARCEL SIZE LAND USE APPLICATION# A <br /> OWNER NAME �/`'/ � /�✓ PHONE yr <br /> OWNER ADDRESS CITY/STATE/ZIP ^� <br /> CONTRACTORL�/� I`!�/� �/"'�L_ •`�'�'/ ( PHONE <br /> CONTRACTOR ADDRESS I�f l�C�lL�1yC' /� CITY/STATE/ZIP <br /> SUBCONTRACTOR 1� /�/� PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STAT <br /> E/ZIP <br /> LICENSE k7C-57 0-61 ❑ D-09 ❑ Other NUMBER �W4f // EXPIRATION DATE <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane (4392) 1 1 Arsenic(4393) <br /> INTENDED USE I.J90omestic/Private (rrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Ch �7o <br /> ❑ Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Num <br /> TYPE OF WORK Vew Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other AP <br /> — <br /> ❑ Monitoring Well(s) #of wells ❑ Soil Boring #of borings s) I 1 Geotechnical 0-.60, <br /> ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair SOA UIN COUNN <br /> 'Ahew Pump ❑ Pump Replacement 11 Pump Repair ❑ Raise Well Casing H ENVIRONMENTAL, <br /> WELL CONSTR CTION I ENT <br /> Drilling Method)i&ud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool Cl Push Point ❑ Other <br /> i <br /> Proposed Well Depth ytV /'Tt Excavation in diameter 1 l Open Bottom AOtravel Pack/Gravel Size � in diameter <br /> ❑ Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter—if— in Thickness/Gauge/ASTM Sched 64 ❑ Steel 101astic CI Stainless Steel ❑ Other <br /> Grout Seal Depthdvv ft El Neat Cement(94 Ib bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water <br /> 110entonite(20%solids) ❑ Other <br /> Grout Placement Method umped ❑ Free Fall ❑ Other 1-1 Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller ump Contractor CI Other <br /> ❑ Concrete Pedestal ❑ Imensions:Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe <br /> PUMP ubmersible❑ Turbine ❑ Other HPPump Set / 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 /> MINI CE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 9.53-3697 <br /> SIGNED — TITLE i�f�� /''�'c DATE <br /> u <br /> I 4-el <br /> v <br /> EP RTMEN U E Z'ilvLY <br /> Application Accepted By j Z I• Dates l Area_�/qdq Employee ID#k,6�4 <br /> Grout Inspection By am1fliaA Date 61f/ U SPECIAL Well Permit <br /> Pump Inspection By Date I l WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMME44TS <br /> e 21 <br /> PE SC Received Che Amount Date Permit/ Invoice# Well ID# <br /> Codes Info By, Cash Remitted Service Request# <br /> S s� I <br /> ?.,3 <br /> 34a;' , <br /> EHD 43-06 8/01/16 WELL/PUMP PERMIT <br />