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WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 18138 EAST HAZELTON AVENUE - STOCKTON CA 95205 - 12091 lRR-3a7r <br />NUN-KEFUNDABLE PERMIT <br />JOB ADDRESS <br />CROSS STREET Im <br />OWNER NAME <br />OWNER ADDRESS I'M <br />CONTRACTOR —m—a& <br />CONTRACTOR ADDRESS 1101 <br />SUBCONTRACTOR <br />SUBCONTRACTOR ADDRESS <br />NZEKEE <br />MOM <br />953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />NO <br />CITY/ZIP <br />tCEL SIZE `3"- LAND USE <br />'APPPLL�ICATTIIOON # <br />I <br />PHONE 'r ( <br />- - 1; F 44-10-- <br />CITY/STATE/LP Z(*tDNjl�� Zl � <br />_ PHONE 2 -01 -'Il /"1- q27-- I C12JS <br />CITY/STATE21P_ <br />LICENSE C-57 ❑ C-61 ❑ D-09 ❑ Other NUMBER � V EXPIRATION DATE <br />DOMESTIC WEL` S#MPLING:)6GeneraI Mineral/Coliform Bacteria (4391)A Dibromochioropropane (4392) ❑ Arsenic (43931 <br />PHONE <br />INTENDED USE )Domestic/Private ❑ Irrigation/Agricultural ❑ industrial DWater Quality Monitoring El Soil Sampling/Characterization <br />,❑ Public Water System <br />If different from Owner: Water System Name Contact Name or Phone Number <br />TYPE OF WORK -ew Well XReplacement Well ❑ Well Alteration/Modification ❑ Other <br />t.I Monitoring Well(s) # of wells ❑ Soil Boring(s) s of borings U Geotechnical 0 of borings <br />❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal U Cross -Connection Repair <br />❑ New Pump ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br />WE CON TRUC N <br />Drilling Method ud Rojo ❑ Air Rotary ❑ Auger ❑ Cable Too[ ❑ Push Point ❑ Other <br />Proposed Well epth�It Excavation 11 in diameter ❑ Open Bottom LKGravei Pack/Grevel Sizin diameter <br />ElConduct r Casing in diameter / Conductor rasing Depth ft <br />Well Casing Diameter in Thickness/Gauge/ASTM Schad_ ❑ Steel Plastic 11 Stainless Steel ❑ Other <br />Grout Seal Depth I It ❑ Neat Cement (94 Ib bagi5-10 gal water) ❑ Sand Cement sack mix/7 gal water <br />Qentonite (20% solids) ❑ Other <br />Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other ❑ Retardant / Accelerator (name) <br />PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other <br />❑ Concrete Pedestal UDimensions: Width ft Length ft Thick in ❑ Christy Box -I Stove Pipe <br />PUMP ❑ Submersible❑ Turbine ❑ Other HP Pump Set <br />It 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 COMPENSATION LAWS. <br />M UM 48 ADVANCE NOTICE REQUIRED FOR INSPECTI N`S- 1PLEASE CALL (209 953-7697 <br />SIGNED TITLE Df4 jVrz-P�y �t Af ISI QJ jdL DATE <br />L-Application <br />DEPARTMENT USE ONLY <br />Cl <br />Accepted By Date 7 % <br />Grout Inspection By — r Date 1,2 <br />Pump inspection By ,� , f Date <br />V <br />Soil Boring Inspection By Date <br />COMMENTS Gx1.,fINr. :,relj 1--� br- r'F-,,fyzlrCj. .-IM�r�r�.t�f �n rrPr <br />Area Employee ID# Dli <br />❑ SPECIAL Well Permit <br />❑ WAIVER Received <br />Constructed Well Depth {t <br />ID <br />0 <br />0 <br />m <br />m <br />�F <br />ANT <br />FO <br />PE SC Received <br />Codes Info B <br />Check#/ Amount Date <br />Cash Remitted <br />Permit/ Invoice # Well IDX <br />Service R qu°e�st # <br />L13,10 ipo <br />IS <br />�j- <br />,1— 4-'� o 1-TE1 <br />NeW+--t <br />0 oo,4 ?-v-4 <br />EHD 43.08 8101/18 �' �l/i 1 2 '% Ae,97V � t.il/ r4 �Ji G Wil (�'�L/ 17C'`f��s. E �'V61. /PUMP <br />/PERMIT <br />( �/IWLin/�-1 i'Z4bM.� fz �1 -15/1 ( <br />