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WELUPUMP PERMIT <br /> $SAN JOAOUIN 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 /> JO Z ADDRESS r _ CITY/ZIP L�� Off` <br /> l / M <br /> CROSS STREET 1t(�r ' f APNC�aJ ��-Z -PARCEL SIZE J ((7LAND USE APPLICATION# m <br /> OSJNER NAME `� �� ✓` G �Q I��� Tr of r PHONE <br /> �n V) <br /> / C � � -� a <br /> OWNER ADDRESS "2/4( OZ a/J�, c c�YDI 'T " f P� �1 vb CITY/STATf�F, E/ZIP__ <br /> CONTRACTOR 1�` S.L.6/C s /✓'� `f PHONE <br /> CONTRACTOR ADDRESS _1 A 9 �d I �J ms's^ I�G' CITY/STATE/ZIP <br /> l <br /> SUBCONTRACTOR _ PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE C.57 C-61 D-09 11 Other NUMBER EXPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X _ Y Township Range___ Section <br /> INTENDED USE J Domestic/Private ; rrlgatlon/Agricultural rl Industrial IJ Water Quality Monitoring U Soil Sampling/Characterization <br /> Il Public Water System <br /> If different from Owner: Water System Name —pct ame or Phone um er <br /> TYPE OF WORK ew Well I! Replacement Well D Well Alteration/Modification f l Other <br /> D Monitoring Well(s) #of wells D Soil Boring(s) #of borings C' Geotechnical #of borings <br /> n Out-Of-Service Well U Out-Of-Service Well Renewal 1_I Cross-Connection Repair <br /> !' New Pump Pump Replacement ❑ Pump Repair I:I Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method)(Mud Rotary Ij Air Rotary 11 Auger D Cable Tool U Push Point D Other <br /> Proposed Well Depth 3 SU ft Excavation OZ I in diameter Open Bottom AGravel Pack/Gravel Size in diameter <br /> I 1 Conductor.Casing in diameter / Conductor Casing Depth ft <br /> , <br /> Well Casing Diameter lr2 in Thickness/Gauge/ASTM Sched _ F;r, _1 Steel Plastic D Stainless Steel i Other <br /> Grout Seal Depth ft 1 Neat Cement(94 Ib bag/5-10 gal water) Sand Cement /c/3 sack mix/7 gal water <br /> I Bentonite(20%solids) :I Other <br /> Grout Placement Method Pumped Cl Free Fall I- Other ;, Retardant/Accelerator(name) <br /> PEDESTAL Installed By 1 Driller Pump Contractor Li Other <br /> 'I Concrete Pedestal t:Dimensions:Width It Length ft Thick in D Christy Box FI Stove Pi— <br /> au MP <br /> iePUMP I Submersible r'' Turbine 1 1 Other HP Pump Set It Standing Water Level ft <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 1 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�(� V�Vy a.,,.t Ctl—p- TITLE 0; DATE <br /> D <br /> It lu <br /> ONT _— <br /> S <br /> E N IRO MI1R p1E T <br /> / Z <br /> 4� <br /> DEPARTMENT USE ONLY <br /> Application Accepted By r Date t k6is Area (4-\ Employee ID# <br /> Grout Inspection By4 �Y�R 11 tc�ti�l`"' " Date L7 SPECIAL Well Permit <br /> Pump Inspection By Date I I WAIVER Received <br /> Soil Boring Inspection By Date _ Constructed Well Depth _.. ft <br /> COMMENTS A St C,l 6(z' <br /> PE SC Received Check#/ Amount Permit/ <br /> Codes Info By Cash emitted Date Service Request# Invoice# Well ID# <br /> END 43-06 WELL/PUMP PERMIT <br /> 4/30/12 <br />