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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 /> �y /�/� <br /> JOB ADDRESS ) 21172 �� Fr•trcl�. Ca,�n � CITY/ZIP /�' N�„'���Ot Cot.o1 I �y✓U y <br /> CROSS STREET PrCSCOTT APN 7-0 120 - 2-S PARCEL SIZEIA6 LAND USE APPLICATION III i <br /> OWNER NAME 12-1 (70-32-. <br /> { {4e'-e� Air Aacl / /�/tPHONE 112-/� J0Q3I'�7, <br /> OWNER ADDRESS �Lt -1 �Z1 C rCMCVx l..OtiyI IZA CITY/STATE/ZIP Mat at r"ll-e �L( IF L',t [ 5uh <br /> CONTRACTOR 1t/ 201SGLlICD1 r1l IIN( ax: f. PHONE 5.2- L12-95 <br /> CONTRACTOR ADDRESS I L9 /Y L Ix rS �d CITY/STATE/ZIPIAod e 54 V <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITYISTATE/ZIP <br /> LICENSE *-A<C-57 f] C-61 ri D-09 ❑ Other NUMBE EXPIRATION DATE /­ <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range_ Section_ <br /> INTENDED USE ;5-Domestic/Private ❑ Irrigation/Agricultural 0 Industrial 0 Water Quality Monitoring ❑ Soil Sampling/Characterization <br /> 0 Public Water System <br /> If different from Omer: Water System amentact ame or Phone Number <br /> TYPE OF WORK )Oew Well Replacement Well 0 Well Alteration/Modification ❑ Other <br /> 0 Monitoring Well(s) M of wells D Soil Boring(s) IN of bunngs ❑ Geotechnical If of borings <br /> U Out-Of-Service Well ❑ Out-Of-Service Well Renewal U Cross-Connection Repair <br /> F1 New Pump 0 Pump Replacement 0 Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method K Mud Rotary ❑ Air Rotary ❑ Auger ❑ C)able Tbol U Push Point ❑ Other <br /> I <br /> Proposed Well Depth 106 ft Excavation 1 Y in diameter ❑ Open Bottom >(Gravel Pack/Gravel Siz � in diameter <br /> D Conduct o Casing In diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Schad_2,a _ U Steel Xplastic ❑ Stainless Steel 0 Other <br /> Grout Seal \Depth ! C�.�ft ;] Neat Cement(94 lb bag/5.10 gal water) 0 Sand Cement sack mI gal water <br /> X Bentonite(20%solids) EOther <br /> Grout Placement Method Pumped ❑ Free Fall 0 Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ DrillerPump Contractor 0 Other <br /> Concrete Pedestal �:Dimensions:Width ft Length ft Thick in ❑ Christy Box [] Stove Pipe <br /> uMP [-� Submersible❑ Turbine r, Other HP 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 /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED TITLE DPI,11B�t DATE 3- 1 - /-7 <br /> r <br /> 71 <br /> n <br /> r <br /> I <br /> X 1 <br /> E iv C UN <br /> T Imp <br /> 4f— t7A fCA <br /> DEPARTMENT USE ONLY �? <br /> Application Accepted By l�X///•��� Date -3 L3b-7 Area 4� Employee <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS &-f- JKIr.JleZAL- CDU FOAM AA-e-r-4.I rG-r.PnI <br /> W EL4L- <br /> PE SC Received he Amount Date Permit/ Invoice M Well IDM <br /> Codes Info B ash Remitted Service Re uest M <br /> 341 3 14s.� 3 � � t2- 0 0D <br /> EHO 4308 WELL/PUMP PERMIT <br />