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r WELL/PUMP PERMIT <br />t SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205.6232 (209) 468-3420 <br />NUN-KEFUNDAB E PERMIT <br />www.sjgov.org/ena <br />IzXPI t, T YEAR FROM DATE ISSUED <br />Joe ADDRESSa r p r <br />CITY/zIP <br />� <br />CROSS STREETAPN <br />� <br />O I PARCEL Smgg, <br />LAND USE APPLICATION # <br />I <br />OWNER NAME t lGI <br />�I �Gj`)'✓)�J�S- <br />OWNER ADDRESS <br />CITYISTATE/ZIP <br />CONTRACTOR C �jl <br />` <br />PHON'gb6))C4Vk,,oy6q <br />CONTRACTOR ADDRESS & <br />CITY/STATE/ZIP <br />Lam]r] <br />NV 'C 651- <br />SUBCONTRACTOR/CONSULTANT <br />JA <br />PHONE <br />SUBCONTRACTOR/CONSULTANT ADDRESS <br />I <br />CIT(YISTATE/ZIP_ <br />LICENSE �( C-57 C-61 D-09 <br />Other <br />NUMBER <br />OJ <br />EXPIRATION DATE 6 <br />BILLING PARITY`: OWNER <br />CONTRACTOR <br />SUBCONTRACTOR/CONSULTANT <br />DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic (4393) <br />NTENDED USE DomesticJPrivate 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 WORK /IQNew Well Replacement Well Well Alteration/Modification Other <br />/// ___Monitoring Well(s) # of wells Soil Boring(s) n of (wrings Geotechnical a of borings <br />Out -Of -Service Well Out -Of -Service Well Renewal Cross -Connection Repair <br />New Pump PUMD Replacement PUMD Repair Raise Well Casino <br />Drilling Method>eMud Rotary Air Rotary Auger Cable Tool Push Point Other <br />Proposed Well Depth Wo ft Excavation (;�— in diameter Open Bottom )(Gravel Pack/Gravel Size in diameter <br />Condu or Casing in diameter I Conductor Casing Depth ft <br />Well CasingDiameter n Thickness/Gau eIASTM Sche_ Steel X Plastic Stainless Steel Other <br />9 <br />Grout Seal Depthft Neat Cement (94 Ib bag/5-10 gal water) Sand Cement sack mix/7 gal water <br />/KBentonite (20%solids) Other <br />Grout Placement Method numped Free Fall Other Retardant / Accelerator (name) <br />PEDESTAL Installed By Driller Pump Contractor Other <br />Concrete Pedestal Dimensions: Width It Length ft Thick in Christy Box Stove Pipe <br />PUMP Submersible 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 COMPENSATkON LAWS. <br />MINIM 48 A NC E REQUIRED FOR IN,S� C{TIgNSi PLEASE CALL (209) 3-7 97 <br />SIGNED T.. ' I ✓lil/ DATE <br />%DEPARTMENT <br />U E ONLY <br />Application Accepted By �`yLi Date o of <br />Grout Inspection By Yf4e\,,Sia �y}titb �IT Date <br />Pump Inspection By Date <br />Soil Boring Inspection By Date <br />COMMENTS <br />Area —/ c Employee ID# / 'r <br />SPECIAL Well Permit <br />WAIVER Received <br />Constructed Well Depth th ft <br />_La <br />N <br />�MFNT <br />09 20?1 <br />//NCO <br />MFNTa NTY <br />