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WELL / PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3""FL-STOCKTON CA 95202 <br /> NON-REFUNDABLE PERMIT (209)468- L <br /> / <br /> CALL(209 953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUE] <br /> JOB ADDRESS ` ' r �- <br /> // CITTYIIZI <br /> CROSS STREET `��yl APN �L C 3 G <br /> PARCEL SIZE <br /> OWNERNAME .._ /1"�- t�JR'% ._ _ R <br /> f PHONE <br /> OWNERADDRESS 7>7)F-'e <br /> ��� < _ <br /> CITVISTATE/ZIP 7>7)F-'e <br /> CONTRACTOR < c <br /> PHONE !/ J <br /> CONTRACTOR ADDRESS - <br /> 7.Z� >e- <br /> SUBCONTRACTOR <br /> ! LZ CETYISTATE/LIP <br /> SUBCONTRACTOR '�} -�__--- PIIONE <br /> SUBCONTRACTOR ADDRESS f-- - <br /> CIT <br /> Y/STATEIZI P <br /> LICENSE ❑C-57 ❑C-61 ❑D-09 ❑Other NUMBER EXPIRATION DATE <br /> GEOGRAPHICALINFORMATION: Coordinates X Y TOWnship Range Section <br /> INTENDED USE ❑Domestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization <br /> ❑Public Water System <br /> If different From Owner: year <br /> ystetn ame ontact Name or Phone Number <br /> TYPE OF WORK ❑New Wen ❑Replacement Well ❑Well Alteration/Modification ❑Test Hole ❑Other ' <br /> 13 Monitoring Wellnumber of wells numbfbi <br /> eroorngs(s} EI Soil Boring(s) ❑Geotechnical numberufborinbs <br /> ❑Well Destruction ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal <br /> ❑New Pum ❑Pum Re lacement ❑Pum Re air ❑Cross-Connection Repair <br /> WELL CONSTRUCTION <br /> Drilling Method ❑Mud Rotary ❑Air Rotary ❑Auger ❑Cable Too] ❑Push Point ❑Other <br /> Proposed Well Depth ft Excavation in diameter 13Open Bottom 11Gravel Pack I Gravel Size in diameter <br /> Q Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑Steel ❑Plastic ❑Stainless Steel ❑Other <br /> Grout Sea! Depth tt ❑Neat Cement(94 lb hub/5-10 gal waler) ❑Sand Cement s'uck,nis l 7 gal water <br /> ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs On File ❑Specs Submitted <br /> t <br /> Grout Placement Method had ❑Pum ed <br /> p El Free Fall ❑Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑Driller 11 Pump Contractor ❑Other <br /> C7 Concrete Pedestal Dimensions: Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe <br /> PUMP ❑Submersible ❑Turbine ❑Other HP Pump Set ft Standing Water Level ft <br /> -------------------- <br /> WELL DESTRUCTION yeg Bottom ❑Gravel Pack ❑Uncased ❑Other <br /> Well Dia ter _ in Total Depth ft Depth to Water ft ❑Casing to be Perforated from ft to ft <br /> Sealing Material ❑Neat Cement(94 lb hag/5-10 gal water) Cl Sand Cement suck rniv/7 gal water l!ientonite Pellets !� <br /> 4 Bentonite(20%solids) ❑Manufacturer Spec%solids % Name 1P <br /> ❑Specs on File ❑Specs Submitted <br /> Placement Method ❑Pumped ❑Free Fall ❑Other <br /> ❑Complete with Mushroom Cap tl below grade ❑Complete to Existing Surface Pad <br /> 1 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. 1 ALSO CERTIFY THAT MY REQUIRED L[CENSE i5 <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> Mlr1M 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> SIGNED Y/ ✓' / JJ! TITLE �� <br /> DA'I'?i <br /> n <br /> V <br /> I YIC S <br /> DEPARTMENT USE ON Y <br /> Application Accepted By v ty.t_ _y Date I b 3-- Area 2— Employee 1D# <br /> Grout Inspection By Dale ❑ SPECIAL Well Permit <br /> Pump Inspection By �f^ Date <br /> Destruction Inspection B 11 WAIVER Received <br /> y�// 'z Dates= ��f�G Constructed Well Depth ft <br /> COMMENTS7. <br /> PE SC Amount Chee Received Permit/ <br /> Codes Info Remitted Cash BV Date Service Request# Invoice# Well ID# <br /> EHD 43-02-006 <br /> 5/7/2002 r MASI-ER WATER WELL PERMIT <br />