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A <br /> " WELUPUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTN DEPARTMENT 1868 EAST HAZELTON AVO"-STOCKTON CA 95205 4f 20 <br /> NON-REFUNDABLE PERMIT CALL 209 953.7697 F;2E ImPEEn2n EXPIRES 1 YEAR 2M DATE ISSUED <br /> Joe ADDRESS - e:eCl'>,Pr 1i u a uk Tun Cc, _> <br /> t{tA m <br /> CIrymp <br /> CROSS STREET 1 ? P 4- APN /9 /J 1'/ O-20 Ptl�$Qi UM APPLICATION 0 <br /> owNErt NAME) - n` -, ) •- <br /> a <br /> CONTRACTOR n - o <br /> CONTRACTOR AD[ 6 —FUv <br /> c4d fit (0 <br /> SUBCONTRACTOR / I '/�,1/ ..y/�y 1 <br /> SUBCONTRACTOR ADDRESS I` I I ,f.,'/�C..�►J�$�Tt1A���t�1 z <br /> P <br /> 1241— IrtNl6 I( WV' <br /> LICENSE G57 '/C-61 D-09 EIRRAT1011 DATE <br /> alt — <br /> GEOGRAPMICAL INFQRMATION: COordinateS X Y Township_ R2nge SeWo1 <br /> i INTENDED USE DOmesbC/Pmrate IrrigatiONAgricuttural Industrial Water(Duality Monllring SOB Sampling/Character talion <br /> Public Water System ^ <br /> If dlffemm tram ower nUontipctrawvw*rinew (7- <br /> TYPE OF WORK New Well Replacement Well Well Alteration/Modification Other <br /> Monitoring Well(s) It ofwe"s Sod Boring(s) #Of boring$ .Geotechnical acrb-np <br /> Out-OfService(�/l1/�_ <br /> Out-Of-Service Well Renewal Goss-Connection Repair <br /> New Pump y l—p Replaooment Pump Repair Raise Wall Casing <br /> WF"CON4TRUCT40N -" C <br /> Drilling Method Mud Rotary Air Rotary Auger Cable Tool Push Point Otter 9 <br /> Proposed Well Depth ft Excavation in diameter Open Bottom Gravel PsddGravel Sae in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth__ R <br /> WeB Casing Diameter_in Thidmess/Gauge/ASTM Schell Steel Pbwbc Stainless Steel Other V <br /> Grout Seal Depth ft Now Cement(94 W b&95-10 go/water) Sand Cement seek rnot/7 gal anter <br /> Bentonite(20%Solids) <br /> Grout Placement Method Pumped Free F&I Other Retardant/Accelerator(none) <br /> PEDESTAL Installed By Driller —Pump CV*.tar Other <br /> Concrete Pedestal Dimensions:Width_ft Length R Thick in ChrWy Box - pipe <br /> PUMP Submersible Turbine Otiler HP Pump Set R Water Level /'�`.. ft <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE M 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 /> MI IMUM 24 HOUR ADVANCE NOTICE REQUIRED F(?RQINSPECTIONS-PLEASE CALL(209)953-7697 <br /> IA- <br /> SIGNED �� TITLE VI) VI / <br /> ('-P M { Vj <br /> DATE I I j / <br /> N <br /> AVa <br /> V <br /> I <br /> Want� <br /> AN 2 3 <br /> e �fl','��EN-AL HEALTH <br /> y 9WISERVICES <br /> F V�T <br /> ,1qN o <br /> EiP RTNIUSE N Y h Oq�� ?O1J� <br /> CO <br /> Application Accepted By Date ( A.* Erripbyee ID# 'tiylRo p E � <br /> Grout inspection By Date ell Permit FM <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Inspection By Date Corlshvcted Weill Depth It <br /> COMMENTS <br /> PE SC Received Amount <br /> Codes �Info B Rernitbd Dau Servi P«arraa t i klvoiu A WeY IDS <br /> 4�1 a�7�3 <br /> EMO+-0E <br /> +ria 12 WEi IPUW PERNrT <br />