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WELL / PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3NO FL-STOCKTON CA 95202 - (209)465-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED <br /> JOB ADDRESS IG 4 CITYIZIP_ 4 7DO M�J m <br /> CROSS STREET rgeJ j�jo <br /> — /I vr., APN^O ?0-Z41-l6 PARCEL SIZE �LAND USE APPLICATION <br /> OWNER NAME JE09AIU101 PHONE # <br /> >OWNER ADDRESS 0(o T� l ^ yPAe=P CITYISTATEIZIP .VWi M 171 <br /> - <br /> CONTRACTOR 061L 0. ftDrCSO=i) <br /> f /T�_!/(�L. PHONE Za9-3 4 7-3 7-6 r <br /> [O <br /> CONTRACTOR ADDRESS _ Z J.V,9(,l.f �e1 / <br /> (AJAV CITYISTATEIZIP [yQ1� 61f M-40, ,- <br /> E SUBCONTRACTOR PHONE <br /> r SUBCONTRACTOR ADDRESS CITYISTATEIZIP <br /> k LICENSE VC-57 ❑C-61 ❑D-09 ❑Other NUMBER t0 r EXPIRATION DATE Q O <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE ❑Domestic/Private ❑Irrigation/Agricultural ❑industrial ❑Water Quality Monitoring Soil Sampling/Characterization <br /> ❑Public Water System <br /> if different fromOwner; Water System Name r c <br /> TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification I ❑dbet, I <br /> k of borings 6 of borings <br /> ❑Monitoring Well(s) #ofwells Soil Boring(s) lad ita�( lt 'iedritl rout <br /> ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal t rosst onn tin I i �� t <br /> ❑New Pump ❑Pump Replacement ❑Pump Repair work being completed or <br /> WELL CONSTRUCTION bXPEwiroPrw al Health Di, <br /> iosion <br /> DrillingMethod ❑Mud Rotary Air Rotary ❑Auger Cable Too[ ush Point ❑Other <br /> Proposed Well Depth I0 -!S ft Excavation 1► in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter <br /> ❑Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑Steel ❑Plastic ❑Stainless Steel ❑Other <br /> Grout Seal Depth 10 - 15 ft Neat Cement(941b bag/5-10 gal water) ❑Sand Cement sack mix 17 gal water <br /> ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name T ❑Specs on File ❑Specs Submitted <br /> Grout Placement Method Pumped Free Fall ❑Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑ Other <br /> ❑Concrete Pedestal Dimensions:Width ft 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 I <br /> WORKERS COMPENSATION LAWS. <br /> NIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> SIGNED TITLE S-Mcr �6rk1CC-1e DATE (0-2 7 <br /> _ t <br /> - <br /> t v� <br /> E-any <br /> I, <br /> „�-- > ,Ye <br /> I i ' s ° te' xi} `F� s a tI Ya "�E Sa .t 4Y 3rd&i „ <br /> s. <br /> p <br /> i tie• ,x' ���w P/�k � Sa' -jy �'� 1' g . <br /> 1 <br /> U U r00 t <br /> I t <br /> S d:T 7 , <br /> t' N EH <br /> I <br /> :D, L <br /> _R,.T:M-E_lil f U'S'E •O-N Y- _ _ —__ w•� <br /> Application Accepted BK _ t Date -� Area Employee ID#� <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Constructed Well Depth ft <br /> COMM T 1 <br /> ' a G <br /> PE SC Received Chec Amount Date Permit/ Invoice# We <br /> Codes Info B Cash Remitted Service Request# <br /> ab <br /> EHD 43-02.006 W ELL PUMP PERMIT <br /> 1/2712005 <br />