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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 INSPECTIO EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS �V�� ITY/ZIP m <br /> CROSS STREET l/ ~� AP/N�2k/1 <br /> 1� _� IW-.C) '� RCEL SIZE_LAND US PPLICA/TTII-ONNN# <br /> /`` <br /> OWNER NAME C VI Y 1 ,y` PHONE: ��•.� "1 / �� m <br /> N <br /> y <br /> OWNER ADDRESS 0 pal . c CITY/STATE/ZIP <br /> CONTRACTOR 11✓ PH`O'NE. b y r <br /> CONTRACTOR ADDRESSy ` 0,K_-1" � �[� CITY/STATE/ZIP <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CIT <br /> Y/ <br /> S <br /> T <br /> AT <br /> E/ZIP <br /> LICENSE -57 ❑ C-61 ❑ D-09 11 Other NUMBER v • EXPIRATION DATE <br /> DOMESTIC WELLS PILING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE omestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ 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 WORKNew 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 /> ❑ New Pump ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br /> WELL CO INSTRUCTION <br /> Drilling Method Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other <br /> Proposed Well DepthI Ul� ft Excavation I �, in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel Size in diameter <br /> ❑ Conductor Casing in diameter / Cond ctor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM SchedSDW—Z I ❑ 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 XPumped 1-1 Free Fall ❑ Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller A Pump Contractor CI Other <br /> ❑ Concrete Pedestal ❑D mensions:Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe <br /> PUMP ❑ Submersible L] Turbine ❑ Other HP Pump Set 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 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 COMPENS 10 LAWS. <br /> MINIMUM 8 DV CE NOTICE REQUIRED FOR INSPECT[ 1 S -P EASE CALL (209 943-7697 <br /> SIGNED TITLE DATE <br /> I A f ———JL <br /> A <br /> N � <br /> D ARTMENT USE NLY <br /> r <br /> Application Accepted B Date 7'lj Area Employee ID <br /> Grout Inspection By i Date ra- SPECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Igspection By Date Constructed Well Depth ft <br /> COMMENTS [��� <br /> PE SC ReceivedCheck Amount Date Permit/ Invoice# Well ID# <br /> Codes Info By Cash Remitted Service Request# <br /> 2 20W , LQ W W`k <br /> 2 20 <br /> d <br /> EHD 43-06 8/01/16 WELL/PUMP PERMIT <br />