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WELL/PUMP PERMIT <br /> • SAN JOAQwN COUNTY ENVIRONMENTAL HEALYN DEPARTMENT 1968 EAST HA LTON AyEli-STOCKTON CA 95205-(299)4983420 <br /> NON-REFUNDABLE PERMIT CALL <br /> \/ /,1 CIA�LL(2209)��9953.7697 FOR INSPECTION!hq EXPPIR//ESS 1 YEAR FROM DATE ISSUED <br /> " Mil <br /> JDs ADDRESS C-I V G l Vf I1YV {�R�1•�(1`� / (.RYI21P �1 `� ti q �i 337 g <br /> CROS STREET APN (AIN -3 DOJp PARCEL SOPLANp USE PLK:ATN)NN <br /> OWNER NUIE 1 , �t . '- N <br /> OWNER ADDRESS • D �//II 1/(1 j/�j r6 Cl CnmY/gTA \ '] <br /> CONTRACTOR IT . a •T5 L4 • /L (PHONE b.) D ^�_\• <br /> CONTRACTOR ADDpE�(9��5I�. • CGY/STA L�1/-C� ri /p S \v <br /> SUSCONTRACTo, I ,T/�� PHONE <br /> N -A C <br /> SUSCONTRADTORADDRES II _ CRYfSTATe/ZIP •_ <br /> L.Icuss r-57 7C-61 D-09 Other Z� NuNeat2- U(II(f 0 Ex "Mor,DATE rt <br /> GEOORAPINDAL INPDR CoordinatesX Y TownShlp_ Range_ Section_ S' <br /> INTENpEO UbE OATOM:mesur/privaus MgatlonfAgrimloral Industrial Water Quality Monitoring Soil Sampling/Characterization <br /> Public Water System s �, <br /> NUMemrtean Owner: m Name aroa <br /> C � <br /> TnEOFWORK New Wall Replacement Well Well AlteraSonlModication Other <br /> sere` <br /> Monitoring WMI(s) #of"its Soil Banng(s) pot b." Geoteohnical <br /> OwofSmic3 Well Out-Of-Se.Mce Well Renewal Cross-Connecbon Repair (� <br /> New Pum ✓Pum Re eoement Pump Repair Raise Well Casino <br /> WEU CONSTRUCTION <br /> Drilling Method Mud Rotary Air Rotary Auger Cable Tod Push Point Other <br /> Proposed Well Depth ft Excevedon in diameter Open bottom Gravel PaddGnvd Sae In diameter <br /> Conductor Caeing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_In Thickness/Gauge/ASTM Schell Steel Plastic Stainless Steel Other <br /> Grout Seal Depth_ft Nest Cement(94 111 bags gel wafer) Sa"Cement sack mild]gal water <br /> Bentonile(20%solids) Other <br /> Grout Placement Melhod Pumped Free Fall Other Retardant/Aealleni(name) n <br /> EWMAL Installed By Dinner Pump Contractor Other 9 <br /> Concrete Pedestal Dimensions:Width_tt Len It Thick in Christy It Btove Pi e <br /> (PUMP V Submersible Turbine Other HPI Pump Be ft Standing Water Level ft 9 <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WfTN 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 /> MINIMU 24 HOUR ADVANCE NOTICE REQUIRED FO�IINSPECTIONS-PLEASE <br /> CALL(209)953 897 W <br /> SIGNED TITLE -r._ _n_ v�.�(rn �j DATE I �'jm <br /> REC NED <br /> A� 0420 <br /> SA N JOAQ <br /> IIIA <br /> 02 <br /> 172 1.21111 1 <br /> COU"M <br /> CESVE� <br /> L 2 5 2016 <br /> NMENTgI H <br /> MIT/SEHyICEE4LTH <br /> /,I1 y/�� 11- DEPARTMENT�{1KWON LY ,_�,` ^r(I,� <br /> Application Accepted By Aye. Date lilt '' �� Area 0 4- Employee 10#,��"" <br /> Grout Inspection By Data _i SPECIAL Well Peninit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PEC <br /> Received Che Nnount Deo Pe^^W Invoice Well IDN <br /> I Codea Info B Remitted SarviceR asst# <br /> I 05D a3 D 1.3 118 -y-Ib S t70 <br /> EXD+YOF WELL PUMP PERMIT <br /> ano•s <br />