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r <br /> WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> 4 /� <br /> JOB ADDRESS C-) 1 I (`�U !� Y!" CITYILP I— ( CI I V m <br /> D <br /> LL 1/ L L :Ity 0 <br /> CROSS STREET L (�-e U I N1cl tl I rAPNDb I I�' O -f PARCEL SIZE LAND USE�/A'�IPPLIC//A`�TION# /�J m <br /> OWNER NAME C2q 1r�I Y O e- ffi 111 PHONE 1 70 7 �(, / y <br /> C3 <br /> C 1 <br /> OWNER ADDRESS I�J Q ' `�C,T^f V` A\l e CITY/STATEILP L�r-�1 I, /C`A � ��"1 C) <br /> CONTRACTOR -J cj 11i/ A I�`t/1 11t Y\ C' / PHONE _k-,9 - {�c7 G <br /> CONTRACTOR ADDRESS f' (- I'C-J� 41 c�C CITY/STATE/ZJP (:lel I + C A C 1 7 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZJP <br /> LICENSE C-57 C-61 D-09 Other-- NUMBER- 7 PI E <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y sRal nge w e <br /> INTENDED USE Y DomesticlPrivate -I Inigation/Agricultural 'Industrial ,Water Qu ity MfflMAg �SKI ISS111hpiffiglChMI1111FAzakA <br /> Public Water System <br /> If different from Owner: watef system Name 1AIlt <br /> ti} <br /> TYPE OF WORK New Well L:Replacement Well Well Alteration/Modification t (pty��(� <br /> 7 Monitoring Wells) #of wells C Soil Bodng(s) #°vdX _ ted b s 6 tie.d <br /> Out-Of-Service Well Out-Of-Service Well Renewal <br /> New Pum C Pum Replacement L Pum Repair pyUlal Health, Divi m <br /> ! <br /> WELL CONSTRUCTION <br /> Drilling Method xr Mud Rotary F Air Rotary !- Auger Cable Tool Push Point Other <br /> Proposed Well Depth 3')G ft Excavation I in diameter Open Bottom x Gravel Pack/Gravel Size Il4_ in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter-[L in Thickness/Gauge/ASTM Sched( � I 4) Steel Xplastic Stainless Steel -:Other <br /> Grout Seal Depth 7(:(; ft ❑Neat Cement(94 lb bag15-10 gal water) ')4 Sand Cement (! sack mixr1 gal water <br /> Bentonite(20%solids) Li Other <br /> Grout Placement Method APumped Free Fall :Other _Retardant/Accelerator(name) <br /> PEDESTAL Installed By4 Driller Pump Contractor Other <br /> Concrete edestal 'Dimensions:Width Lft Lengthft Thick C in I Christy Box I StovePipe <br /> PUMP Submersible Turbine Other HP � Pump Set__L(, -) 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 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MINIMVM <br /> 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-}PLEASE CALL(209)9953-7697 <br /> SIGNED TITLE V �t C I,t C7 r Cl C�11 DATE JJU/ICS <br /> I FF <br /> PAYME V I I A,I ' <br /> RECEI <br /> r <br /> JUN 13 <br /> TY <br /> yN JOAQUM C U <br /> EHVIRONbt <br /> HEALTH DEP <br /> _DFPAIRTMENT U E N L Y <br /> Application Accepted Date (tj7�( Area44 qj Employee ID#r,:� G <br /> eD <br /> Grout Inspection By Date 7 SPECIAL Well Permit <br /> Pump Inspection By Date I WAIVER Received <br /> Soil Boring Inspection By D to Constructed Well Depth it <br /> COMMENTS �� <br /> PE SC Received Check#/ Amount PenniU <br /> Codes Info By Cash Remitted Date Service Re uest# Invoice# WeIIID# <br /> < 01411-Alli <br /> sv s3." ot�piv V-00-)o <br /> WELL/PUMP PE;i MIT <br /> 4/3Cn2 Y/' <br />