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�r WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONAENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 53-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE�ISSUED <br /> JOB ADDRESS CRVZP <br /> � <br /> O2-DO-2�0 <br /> CROSS STREET APN PARCEL SIZE 4 LAND USE APPLICATION# o <br /> OWNER NAME X (�I V <br /> PHONE <br /> CII$TATE(ZIPr A OWNER ADDRESS 4J'� re' <br /> �7 <br /> CONTRACTOR <br /> CONTRACTOR ADDRESS l� I CITY/STATE/ZIP <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CRY/STAITnE/ZIP <br /> LICENSE -C-57 ;]C-61 0 D-09 L Othef NUMBER01," ExPIRATION DATE l <br /> DOMESTIC WELL SAMPLING:o General Mineral/Coliform Bacteria(439 1) Dibromochloropropane(4392)i.]Arsenic(4 393) <br /> INTENDED USE X Domestic/Private (I Irrigation/Agricultural :i Industrial Water Quality Monitoring ❑Soil Sampling/Characterization <br /> ❑Public Water System <br /> If different from Or Water System Name Contact Name or Phone Number <br /> wne <br /> TYPE OF WORK }(New Well C Replacement Well ❑Well Alteration/Modification ❑Other <br /> 1.Monitoring Well(s) #of wells -)SOil Bonng(s) N°f Dor1nv' Geotechnical K of borings <br /> fOut-Of-Service Well 0 Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> is New Pump 11 Pump Replacement 0 Pump Repair ❑Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method XMud Rotary ❑Air Rotary it Auger Li Cable Tool C Push Point G Other <br /> Proposed Well Deplh�it Excavation_1�in diameter ^Open Bottom Gravel Pack/Gravel Size in diameter <br /> IJ Conductor Casing in diameter / Conduct r asing Depth ft <br /> Well Casing Diameter In Thickness/Gauge/ASTM Shed ❑Steel Plastic C Stainless Steel I Other <br /> Grout Seal`Depth it ❑Neat Cement(94 Ib bagl5-10 gal water) -1 Sand Cement sack mixt]gal water <br /> y!Benlonite(20%solids) -1 Other <br /> Grout Placement Method vpumped D Free Fell D Other D Retardant/Accelerator(name) <br /> PEDESTAL Installed By tl Driller D Pump Contractor ;i Other <br /> Concrete Pedestal❑Dimensions:Width it Length ft Thick in C!Christy Box ❑Stove Pipe <br /> PUMP _Submersible[]Turbine ❑Other _ HP Pump SetH Standing Water Level ft <br /> J <br /> 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> OAQUIN 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 /> MINIM 4 VANCE NOTICE REQUIRED FOR INSP�C IONS-PLEASE CALL(209)9531--7697 <br /> SIGNED / TITtF� �L� p�ll��^ DATE <br /> q <br /> EQ <br /> 4?0 <br /> Off <br /> Fp q NTY <br /> A C <br /> DEPARTMENT USE ONLY <br /> Application Accepted By �Z—' �— Date /$ �Cdl Area i��Fy' <br /> Grout Inspection By I Employee ID#-1 <br /> Date 11 SPECIAL Well Permit <br /> Pump Inspection By WAIVERReceived 1 <br /> Soil Boring Inspection By Date <br /> Date u eceived <br /> COMytENTS - �p Constructed Well Depth R <br /> eoo­l W1 a ;f 1 ,�.�s t•t NtfYt,�+1�✓I1 xcoV. % 03. 5 d�ans�l <br /> r `e lacL 911 {� I�� <br /> PE SC Received CheckiN Amount <br /> Codes Into Cash Date Permit/ n <br /> C. _ Remitted Service R uest# Invoice# Well ID# v <br /> O S� 4:,I " <br /> A- ISO " r <br /> it t (�In Q� "�✓ <br /> EMO 13-01 8,111116 /(/ <br /> ffl` pI WELL/PUMP PERMIT Obt) ��jj qql{ <br /> [/ �O <br />