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WELL/PLUMP 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 /> /� 7( <br /> . JOa ADDRESS A 7o S L(��//n 4) E_ Gn,NnP / �/C, 1 `" <br /> CROSS STREETC� GKr APN OI[J () 3 SCJ o <br /> ARCEL Slims LAND USE APPLICATION 4 r7 <br /> OWNER NAME l-L� rLi4= •�� m <br /> PHONE <br /> SLLa <br /> OWNER ADDRESS nJ ;Q�y /; ^�" <br /> CONTRACTOR b <br /> ' ' PHONE <br /> CONTRACTOR ADDRESS -S CITY/STATFJLIP q-5. m <br /> SUBCONTRACTOR !!! PHONE /Y <br /> SUBCONTRACTOR ADDRESS CITY/STATEMP <br /> LICENSE C-57 C-61 D-09 Other NUMBER EXPIRATION DATE I n <br /> GEOGRAPHICAL INFORMATION: 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. a er ys em ame Qontad NaMe or orro um r <br /> TYPE OF WORK XNew Well Replacement Well Well Alteration/Modification Other <br /> Monitoring Well(s) #of wells Soil Bonin9( )s o of borings Geotechnical u of borings <br /> Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair <br /> New Pum <br /> Pump Replacement Pump Repair Raise Well Casin <br /> WELL CONSTRUCTION <br /> Drilling Method>( Mud Rotary Air Rotary Auger I Cable Tool Push Point Other <br /> Proposed Well Depth -? 70 ft Excavation�_I in diameter Open Bottom Gravel Pack/Gravel Size_in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter-Lin Thickness/Gauge/ASTM Sched S Q)r'Z% Steel n Plastic Stainless Steel Other <br /> Grout Seal Depth I QQ ft Neat Cement(94/b bag/5-10 gal water) J�Sand Cement ? r sack mix/7 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method Pumped Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By x Ddfler Pump Contractor Other <br /> X Concrete Pedestal Dimensions:Width It Length ft Thickn Christy Box Stove Pipe <br /> PUMP Pump Set :.1r'�Q 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 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MINIMUM 24 HOUR AD E NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNEDDATE!' TTn.E <br /> V ,� j <br /> 1 d #('j <br /> 1 r <br /> r t� <br /> PL- <br /> kd <br /> J <br /> (j, <br /> DEPARTMENIT22LI E O LY 4; <br /> Application Accepted By Date J Area r`r Employee ID# <br /> Grout Inspection By Date g ❑ SPECIAL Well Permit <br /> Pump Inspection ey Date 0 0 ❑ WAIVER Received- <br /> Soil Boring Inspection By DateConstructed Well Depth <br /> CO •'L- ft <br /> ME TS A-e- eN L <br /> PE SC Received ChecldN Amount Permit) <br /> Codes Info Cash Remit Date ���R Invoice# Well ID# <br /> `F3lo (8a 3736(.o 3 IC�67(o9 <br /> `f3Ssu cas'o "Z o. 3 r <br /> r EHD 43-06 <br /> 4130112 WELL!PUMP PERMIT <br />