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WELL/PUMP PERMIT <br /> SAN JOAQUIF,COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 <br /> NCfl-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS ' Z 7 – CITY/ZIP m <br /> � D <br /> CROSS STREET � �/ <br /> LamC' ` anf &'J eAPN 1 PARCEL SIZE LAND USE <br /> APPLICATION# z <br /> cn <br /> OWNER NAME �L�Iy/�-�� PHONE i0 '0 <br /> OWNER ADDRESS 00, C 079e 13:/f CITY/STATE/ZIP <br /> CONTRACTOR �, //L�` f7//�/J,/s' T/ � ��h�—/fyl �PHONE <br /> /// <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP ,7✓ %L� /�,G �� <br /> SUBCONTRACTOR lr /!-ASN PHONE <br /> SUBCONTRACTOR ADDRESS CITY <br /> /STATE/ZIP <br /> LICENSE -57 -61 ❑ D-09 ❑ Other NUMBER L!C EXPIRATION DATE / 3l <br /> DOMESTIC WELL SAMPLING: I General Mineral/Coliform Bacteria (4391) _i Dibromochloropropane(4392) i Arsenic(4393) <br /> INTENDED USE ❑ Domestic/Privaterrigation/Agricultural 1-1Industrial 11Water Quality Monitoring Ll Soil Sampling/Characterization <br /> ❑ Public Water Sy6tem <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 /> 3tAew Pump ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRU TION <br /> Drilling Method AMud Rotary ❑ Air Rotary ❑ Auger CI Cable Tool ❑ Push Point ❑ Other <br /> Proposed Well Depth2-512 ft Excavation /I in diameter ❑ Open Bottom Gravel Pack/Gravel Size in diameter <br /> ❑ Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casting Diameter_J0 in Thickness/Gauge/ASTM Sched 41Z� ❑ Steel WPlastic ❑ Stainless Steel ❑ Other <br /> Grout Seal Depth .50 ft ❑ Neat Cement(94 lb bag/5-10 gal water) &0tand Cement sack mix17 gal water <br /> altentonite(20%solids) ❑ Other <br /> Grout Placement Method umped ❑ Free Fall ❑ Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller Xpump Contractor ❑ Other <br /> ❑ Concrete Pedestal ❑ ensions:Width ft Length ft Thick in ❑ Christy Box CI Stove Pipe <br /> PUMP )tt?ubmersibleii Turbine ❑ Other HP Pump Set ft Standing Water Level © ft <br /> I HEREBY C RTIFY 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 /> MIAA� li� ANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 5 -7697 <br /> SIGNED J` L7 �/� TITLE DAT <br /> Ail <br /> N <br /> H 1111 TH DE'Al <br /> A TMENT U E ONLY <br /> AWApplication Accepted By Date Area ell Employee ID# <br /> Grout Inspection By Date U PECIAL Well Permit <br /> Pump Inspection By +moi SC�.0 vi, ` &"� Date �l�*Le 1'1�'W Ll WAIVER Received <br /> Soil Boring Inspgction y Date Constructed Well Depth ft <br /> COMMENTS 9 <br /> PE Sc Received heck#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B Remitted Service Re uest# <br /> a60 M 59 <br /> EHD 43-06 8k01/16 WELL/PUMP PERMIT <br />