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WELL/PUMP PERMIT <br /> SAN JOAOUIN COUNT`.!ENVIRONMENTAL HEALTH DEPARTMENT 1669 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)465-3420 <br /> NON-REFUNDAIkE PE501zCALL 20 953-7691 FOR INSPECTIONS r—EXPIREP 1 YEAR om DAJE 1$ UED <br /> JOB ADDRESS CITY/LP <br /> 0 <br /> CROSS STRE APN_ � 7"%Z <br /> TION# <br /> (/�� I wOWNER NAME "" t ✓ �� 2 (0 'OWNER ADDRESS ��// y/ Vl d Y - )✓— <br /> I Q / �J (/fir P NE <br /> CONTRACTOR <br /> CONTRACTOR ADDRESS L CIN/S ATE/ZIP (, � <br /> ,SUBCONTRACTOR P/�•I/N r <br /> SUBCONTRACTOR ADDRESS IT()V/�$TATE/ZIP Al / / � <br /> LICENSE C-57 �C-61 D-09 Other NU r/ EXPIRATION DATE �V <br /> DOMESTIC WELL SPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE V Domestic/Private Irrigation/Agricultural Industrial Water Quality Monitoring Soil Sampling/Characterization a-1 <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/N40dificabon Other <br /> Monitoring Weill #of wells Soil Boring(s) #of bonngs #ofbonngs <br /> Geotechnical <br /> Out-Of-Service We Out-Of-Service Well Renewal Cross-Connection Repair <br /> New Pump j ump 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 it Excavation in diameter Open Bottom Gravel Pack/Gravel Siza in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Schad' Steel Plastic Stainless Steel Other <br /> Grout Seal Depth ft Neat Cement(94 lb bag/5-10 gal water) Sand Cement 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 Driller Pump Contractor Other <br /> itoncrete Pedestal Dimensions:Width ft Leng ft Thick in . Christy Box Stove Pipe <br /> rPUMPV Submersible Turbine Other HIP Purnp Set QV 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 ORDINANC $, STATE LAWS. AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WIT HE ORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION <br /> MINIMUM 24 O AD NCE NOTICE REQUIRED FO NSPECTIOQN�S�-PP�L/E'�A�S/E CALL(209 <br /> SIGNED TITLE �� l I / LI/L I'1 DATE ft v 1 <br /> V <br /> � RE <br /> CF jV�C <br /> J0, <br /> 16 <br /> ' oNM c0147-Y <br /> H DEPgR MFNT <br /> A MENT US O LYSL <br /> Application Accepted By ate L Area Employee <br /> Grout Inspection By Date SPECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring nInspection By Date Constructed Well Depth '�,�) It <br /> COMMENTS t7lILI- �7 1'10 `2 5 (°�GLI A! b 1 tit-L" �1y o 5 Ar_,6 =�i(.L LJ R <br /> 0%1 2PTl2.0\� <br /> PE SC Received C Amount Date Permit/ Invoice# Well ID# <br /> Code Info ash Remitted Service Request# <br /> J <br /> i <br /> EHD 43-06 8101/16 .� K `_'_•C+V �� /r/r V i/ WELL(PUMP PERMIT <br />