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WELL/PUMP PERMIT <br /> SAJOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT IS,7q 2 CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS <br /> CITY/ZIP �IU l ( m <br /> � <br /> CROSS STREET A P N PARCEL SIZE �' '` LAND USE APPLICATION# <br /> I -TD 6 \ `n`�n _ m <br /> OWNER NAME L 1r• PHONE ���) C <br /> OWNER ADDRESS l 1 L CITY/STATE/ZIP h 453 <br /> CONTRACTOR VLI� PHONE <br /> O ��_ <br /> t� <br /> CONTRACTOR ADDRESS L �• �C�� 1��C CITY/STATE/ZIP <br /> SUBCONTRACTOR qPHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP (I <br /> LICENSE AC-57 ❑ C-61 ❑ D-09 -1 Other NUMBER SLI t0 ( EXPIRATION DATE �� � 0 <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE )LDomestic/Private ❑ Irrigation/Agricultural ❑ Industrial 7 Water Quality Monitoring ❑ Soil Sampling/Characterization <br /> ❑ Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK ❑ New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other <br /> ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings ❑ Geotechnical #of borings <br /> ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> 6i-New Pump ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method ❑ Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other <br /> Proposed Well Depth ft Excavation in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel Size in diameter <br /> ❑ Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_ in Thickness/Gauge/ASTM Sched ❑ Steel ❑ Plastic ❑ Stainless Steel ❑ Other <br /> Grout Seal Depth ft ❑ Neat Cement(94 lb bag/5-10 gal water) ❑ Sand Cement sack mix17 gal water <br /> ❑ Bentonite(20%solids) ❑ Other <br /> Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other C <br /> ❑ Concrete Pedestal []Dimensions:Width ft Length It Thick in ❑ Christy Box ❑ Stove Pipe <br /> PUMP %L.Submersiblell Turbine ❑ Other HP Pump Setft 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 /> M11JI11AUM 48 HOUR V NCE NOTICE REQUIRED FOR INSPECTIONS -PLEASE CALL (209) 9 3-7197 <br /> SIGNED ' TITLE /LI' DATE <br /> Ar <br /> 0 <br /> 9 <br /> Tjy /yuz <br /> U <br /> T <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date 0 " I Area U Employee ID#4_-�_ <br /> Grout Inspection By n (fid Date ❑ SPECIAL Well Permit <br /> Pump Inspection E �� \1C�a� � Date ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> Ip <br /> COMMENTS L1 3 q r <br /> PE SC Receivedec Amount Date Permit/ Invoice# Well ID# <br /> Codes Info ash Remitted Service Request# <br /> 05f ► 2 <br /> EHD 43-06 8101/16 WELL/PUMP PERMIT <br />