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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 /> NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS <br /> PER CROSS STREET �.b NAPN ©C\\ - -ZCSC) '3PARCELS > 5 PP 1 <br /> OWNER NAME ��tJ.� A--1 �[J��i1�D SLrc\Ot�t� �7\S'«\C_Mr!711 M <br /> E OWNER ADDRESS CITvW@rr(*eM ( W1e} d or 'ns pFed y <br /> CONTRACTOR Nssd ��� a =nviroa °:gal Health Division <br /> CONTRACTOR ADDRESS "`b L �Q 1IL����L C l W 1Pr"1 CITY/STATE/ZIP L-C] 1 I L A d\S-A d <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE *C-57 ❑C-61 ❑D-09 ❑Other NUMBER �0 10 1J()q- EXPIRATION DATE (3 a' <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED Uff ❑Domestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring gl.§oil Sampling/Characterization <br /> ❑Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification ❑Other <br /> ❑Monitoring Well(s) #of wells ❑Soil Boring(s) #ofborings 9Weotechnical Z #of borings <br /> ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> ❑New Pump ❑Pump Replacement ❑Pump Repair <br /> WELL CONSTRUCTION <br /> Drilling Method ❑Mud Rotary ❑Air Rotary ZAugcr ❑Cable Too] ❑Push Point ❑Other <br /> Proposed Well Depth 17 R Excavation_iin diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter <br /> ❑Conductor Casing in diameter / Conductor Casing Depth ft "J <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑Steel ❑Plastic ❑Stainless Steel ❑Other <br /> Grout Seal Depth R ❑Neat Cement(941b bag/5-l0 gal water) ❑Sand Cement sack mix/7 gal water <br /> ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted <br /> Grout Placement Method ❑Pumped 14 Free Fall ❑Other ❑Retardant/Accelerator(name) f k-%- c --V-r 6,-,t,J <br /> PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑ t <br /> ❑Concrete Pedestal Dimensions:Width ft th ft Thick in ❑Christy Box ❑Stove Pipe <br /> PUMP ❑Submersible ❑Turbine ❑Other HP Pump Set ft Standing Water Level R <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 I/1 <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> t <br /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> SIGNED TITLE �'�I�Fi` EIJ r-E -DATE <br /> FCLu 70'C `Y�. <br /> a KI u, <br /> a <br /> t E <br /> , t <br /> f <br /> P N� <br /> P0FCj+41#4/eR.T 1 <br /> j 41— <br /> F <br /> I <br /> Q �1r <br /> ray <br /> -_���...-1,� -. - _.• �E' A"it T ME'N-T�U S E O N L'Y' <br /> Application Accepted By Date �� d Area Employee ID# 1 �c(� <br /> y <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Constructed Well 77th ft <br /> COMMENTS ell <br /> /J7 fI7 <br /> PE SC Received Check# Amount Date ermit/ Invoice# Well ID# <br /> Codes Info B ash emitted Service Request# <br /> X3=7 1sfl ;�3 3 <br /> ERD 43-02-006 WEI-1,PUMP PERMIT <br /> 1/27/2005 <br />