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WELUPUMP 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 /> YrJ/}I, m <br /> JOB ADDRESS t' CITY/ZIP \] )1 l/r ti� /r CA `- "6 <br /> ( o <br /> CROSS STREE I y�APIN (:/()"!�/\r/ lQ PARCEL SIZE 1_LAND USE APPLICATION# In <br /> OWNER NAME V PHON09g-q0 -g Jl5 <br /> OWNER ADDRESS CITY/STATE/ZIP <br /> CONTRACTOR PHON�EI(/z��"�rj S !��X//�t D."74 L <br /> CONTRACTOR ADDRESS 7n I CITY/STATE/ZIP_'/A.1 /i� glJ�V <br /> SUBCONTRACTOR , PHONE <br /> SUBCONTRACTO ADDRESSITY/STA/rT��/E/ZIP <br /> LICENSE -57 11 C-61 n D-09 11 Other NUMBER 7,/ee r. EXPIRATION DATE OFT <br /> GEOGRAPHICAL INF MATION: Coordinates X Y Township_ Range_ Section_ <br /> INTENDED USE Domestic/Private n Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring U Soil Sampling/Characterization <br /> U Public Water System <br /> If different from Owner: Water System Name ontad ame or one um r <br /> TYPE OF WORK Replacement Well ❑ Well Alteration/Modification ❑ Other <br /> ❑ Monitoring Wells) #of wells ❑ Soli Boring(s) #of borings ❑ Geotechnical #of borings <br /> ❑ Out-Of-Service Well U Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> New Pump ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCAOIN <br /> Drilling Method A Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other <br /> Proposed Well Depth iso. -ft Excavation 0!!� i6diameter ❑ Open Bottom Gravel Pack/Gravel Size t1W in diameter <br /> U Conductor Casing in diameter / Conductor Casing Depth tt <br /> Well Casing Diameter-U— in Thickness/Gauge/ASTM Schad<t1*4D U Steel $,Plastic ❑ Stainless Steel ❑ Other <br /> Grout Seal Depth 100 ft n Neat Cement(94 1b bag/5-10 gal water) ❑ Sand Cement 0.'7 sack mbdor gal water <br /> ❑ Bentonite(20%solids) Il Other <br /> Grout Placement Method ❑ Pumped ❑ Free Fall Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other <br /> n. Concrete Pedestal [-Dimensions:Width_ft Length It Thick in Cl Christy Box ❑ Stove Pipe <br /> PUMP X Submersible[j Turbine r; OtherHP Pump Set�ft Standing Water Level it <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 COMPENSATION LAWS. <br /> MINANNCCE/NOTICE REQUIRED FOR INSPECTIONS- PLEASE CALL(209)95 769 <br /> SIGNED TITLE //blc DATE / <br /> Eato <br /> LM ESEfVIE <br /> M <br /> „ `nne D PARTMENT USE ONLY <br /> Application Accepted Bt, <br /> < DateIq/ �l Area Employee 1134 <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection By _ Date F1 WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth <br /> COMMENTS GO C. REKGII-( i5lriul f/L lE: <br /> PE SC Received a Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B as Remitted Service Request# <br /> 37p X37/ - bQ Q0 Q I1� S 07 <br /> 5 (o <br /> 3 D 751007 <br /> EHD 434e WELL/PUMP PERMIT <br />