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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 41CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS <br /> 5do CITY/ZIP m <br /> ^�nn D <br /> CROSS STREET APN �• PARCEL SIZE LAND USE APPLICATION# A <br /> rn <br /> OWNER NAME oi� PHONE CJ<</ /_ <br /> OWNER ADDRESS �O O CITY/STATE/ZIP <br /> CONTRACTOR Uoo nr`t/V►� /�� /�1A)a /Tr& (� 1 `r �C. PHONE �V'/ ' q, /� (� <br /> CONTRACTOR ADDRESS pC /�V �/Vi1.0x ,4/� CITY/STATE/ZIP If <br /> 4 q5�� <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE C-57 I I 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 I I Irrigation/Agricultural 1_I Industrial ❑ Water Quality Monitoring I Soil Sampling/Characterization <br /> I Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK New Well I Replacement Well I Well Alteration/Modification Other <br /> I Monitoring Well(s) #of wells i Soil Boring(s) #of borings Geotechnical #of borings <br /> Out-Of-Service Well J Out-Of-Service Well Renewal i Cross-Connection Repair <br /> I New Pump XpumpReplacement i 1 Pump Repair I' Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method , Mud Rotary I I Air Rotary I-I Auger i Cable Tool Push Point iI Other <br /> Proposed Well Depth ft Excavation in diameter I I Open Bottom I_i Gravel Pack/Gravel Size in diameter <br /> I I Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched I I Steel I I Plastic 1 1 Stainless Steel I I Other <br /> Grout Seal Depth ft U Neat Cement(94 lb bag/5-10 gal water) I I Sand Cement _-PAYMENTater <br /> II Bentonite(20%solids) 11 Other RECEIVED- <br /> Grout Placement Method I I Pumped I 1 Free Fall 1 i Other I I Retardant/Accelerator(name) <br /> PEDESTAL Installed By I I Driller ❑ Pump Contractor 1 Other iI Ii <br /> Concrete Pedestal I IDimensions:Width ft Length ft Thick in Christy Box Stove Pipe <br /> PUMP Submersiblel Turbine Other HP Pump Set ft Standing WateriNYAIRONMENTALft <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCdk6 iN <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 /> MI4 O VAANCE NOTICE REQUIRED FOR <br /> /Ilt* PP�E�CJTIIONS - PLEASE CALL (209)/95 -7669 <br /> SIGNED Z l ' i�— TITLE Lf'/LE �� DATE (tJ ,/ <br /> 1 1111161 1 '\V <br /> PA T M E N T U E O LY <br /> t , <br /> Application Accepted By Date Area Employee ID# <br /> Grout Inspection By Date ii SPECIAL Well Permit <br /> Pump Inspection By Date ; 1 WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#/ Amount Permit/o Info B mi <br /> Cash etted Date p� Serrvice Request# Invoice# Well ID# <br /> EHD 43-06 8/01/16 WELL/PUMP PERMIT <br />