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WELL / PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3"°FL-STOCKTON CA 95202 - (209)468-3420 <br /> l <br /> NON-REFUNDABLE PERMIT CALL(.209)953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED <br /> F / Z, <br /> JOB ADUREss -7 47 /� %�L r�Y Cr'Y/ZIP �� ,�1G7��i�-� j�Zy �j• <br /> '� c <br /> CROSS STREET W t M fL IL �7—, APN r _ y P L—PARCEL SIZE v'77. LAND USE APPLICATION <br /> t*1 <br /> OWNER NAME PHONE q 47 (J y <br /> OWNER ADDRESS ?41vfL ,A /4,,�,{7y'L CITY/STATE/ZIP <br /> CONTRACTORft ��/ L � f �j�rl PHONE ' <br /> CONTRACTOR ADDRESS-602- /JS/Q j�jf T��/}(� AVJ-( CITYISTATE/ZIP L L;�1 44 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATEIZIP <br /> LICENSE -57 ❑C-61 ❑D-09 ❑Other - NUMBER 40 & Ate <br /> A ION <br /> -I Rzy � j <br /> GEOGRAPHICAL INFORMATION. Coordinates X Y Township e <br /> INTENDED USE ❑Domestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Q al th y/ M Wj80��MTffd Ftion <br /> ❑Public Water System w /" 1�VILIIUI!! <br /> Ifdifferent from Owner: Water ystem Name - yYork r nOf+ e <br /> TYPE OF WORK ❑New Well ❑Replacement Well ❑/Well Alteration/Modification ❑ t ] , a ea+ 1`' - t� <br /> ❑Monitoring Wells) #of wells Soil Boring(s)� #of borings ❑Geotechnical L a of borings <br /> ❑Well Destruction ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal <br /> ❑New Pump ❑PumR R5EiaCement ❑Pump Repair ❑Cross-Connection Repair <br /> W ELL CONSTR UMON <br /> Drilling Method ❑Mud Rotary ❑Air Rotary Auger ❑Cable Tool ❑Push Point ❑Other <br /> Proposed Well Depth ft Excavation /42 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/C'rauge/ASTM Sched ❑Steel ❑Plastic ❑Stainless Steel ❑Other <br /> Grout Seal Depth ft ❑Neat Cement(94 lb hag 15-10 gal water) ❑ and Cement sack mix/7 gal water ` <br /> ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % NameS� G 4 j pecs on File ❑Specs Submitt �1 <br /> Grout Placement Method ❑Pumped 11 Free Fall C3 Other ❑Retardant/Accelerator(name E,,j 7V ALO t ice_ i <br /> PEDESTAL Installed By ❑Driller ❑Pump Cont ctor ❑Other <br /> r. <br /> ❑Concrete Pedestal Dimensions- Width I Le th ft Thick in ❑Christy Box ❑Stove:Pipe f <br /> PUMP 13 Submersible ❑Turbine ❑Ot er HO Pump Set ft Standing Water Level fi <br /> I HEREBY CERTIFY THAT 1 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 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. : <br /> INIMUM 24 HO ADVANCE NOTICE REQUIRED FOR INSPECTIONS1-11 <br />` SIGNED TITLE! 1" `11/2 4 L DATE <br /> I� <br /> FV <br /> 4,F <br /> A <br /> n <br /> SDwALIAD-L <br /> - 1-I <br /> DEI <br /> � J <br /> •D-E-P'A R-T M E-N-T-U-S E KO N"L Y, <br /> Application Accepted By z 1 [�f/ Date f Area Employee I D# cI <br /> Grout Inspection By Date ❑ SPECIAL Well Permit tt <br /> Pump Inspection By t Date ❑ 'WAIVER Received <br /> Destruction Inspection11 <br /> y Date it Construe ed Well Depth ft <br /> COMMENTS 2- I >'r <br /> 7 - <br /> PE SC Received Check#!/ Amount Date Permit/ Invoice# Well ID# <br /> Codes <br /> Info B as Remitted Service Request# <br /> Jf3,/ 4�3� tf•Ou S Pj- Off` E _ <br /> EHD 4M2-006 WELL PUMP PERMIT <br />