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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 INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> Ln <br /> JOB ADDRESSV1 al. CITY/LP �/ / 9 <br /> CROSS STREET Al APINZ PARCEL SItF. LAND USE APPLICATION# S <br /> OWNER NAME 1�`I D' ^ �►[�yP.H/ Ink <br /> A' ('.A <br /> OWNER ADDRESS �.D�l v Am Pic Cm/STATE(ZIP-�.Y�A lDl V 1 V <br /> CONTRACTOR 1.l v' PHONE 201-522. 1gzy <br /> CONTRACTOR ADDRESS CrrYISTATEZP A, <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE21P <br /> LICENSE C-57 0"1 0 D-09 ❑Othar NUMBER FxPIRATION DATE <br /> DOMEsnc WELL SAMPLING:❑General MineraUColiform Bacteria(4391)o Dibromochloropropane(4392)0 Arsenic(4393) <br /> INTENDED USE C DOMOSUCJPrivete rrigation/Agricuftural 0 Industrial ❑Water Quality Monitoring 0 Soil Sampling/Cheraclerizatlon <br /> 0 Public Water System <br /> If daNrernt from Oarar. Wulff System Name Contact Name or Phone Number <br /> TYPE OF WORK New Well 0 Replacement Well 0 Well Alteretion/Modiftcation ❑Other <br /> 0 Monitoring Wells) #of wells 0 Soil Boring(s) a°} "v' ❑Geotechnical e of bort"v0 <br /> 0 Out-OfServlce Well 0 Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> 0 New Pump 0 Pump Replacement ❑Pump Repair 0 Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling MethodXIMud Rot_ ery ❑Air Rotary ❑Auger_❑Cable Tool ❑Push Point 11 Other <br /> Proposed Well Depthj_jJ�j�—R l <br /> Excavation T U 1 in diameter 0 Open Bottom ❑Gravel PecWGravel Size In diameter <br /> 0 Conductor Casing In diameter / Conductor Casing Depth ft <br /> Well Casing Diameter, In Thickness/Gouge/ASTM Sched�— 0 Steel *].slit ❑Stainless Steel n Other <br /> Grout <br /> Seal YYDepth ft ❑Nest Cement(94 Ib bag/5-10 get water) ❑Sand Cement sack mix/7 gal water <br /> /i�Bentonite 20%solids) ❑Other <br /> Grout Placement Method Pumped 0 Free Fall ❑Other 0 Retardant/Accelerator(name) <br /> PEDESTAL Installed By 0 Driller ❑Pump Contractor ❑ Other <br /> D Concrete Pedestal DDlmenslons:Width it Length ft Thick In 0 Christy Box 0 Stove Pipe <br /> PUMP 0 Submersible0 Turbine O Other HP Pump Sel ft Standing Water Level ft <br /> 1 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 /> MINIMUM 48 HOUR A VANCE NOTICE REQUIRED FO IN1 PECTIQN�`PLEASE CALL 209)953-7697 <br /> SIGNED ..D Ulf- uN�V1% DATE <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date l l >; 3 J Area `%( Employee ID# <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection By Date O WAIVER Received <br /> Soil Boring inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#/ Amount Date Permitl Invoice# Well ID# <br /> Codes Info Cash Remitted Service Request# <br /> EHO 43-M 8MI116 //7�3 YJ�7� WELL/PUMP PERMIT <br />