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- X70 �v <br />WELUPUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT CALL 209 9533-7/697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS 1 D y +�i Q %�4 /�� / r���� Z/ "/CITY/ZIP MA nJe_e4 <br />CROSS STREET HILL 1 1 1� �.APN t77 / �T D� I) t Z— PARCEL SIZE t) LAND USE APPLICATIOC%N[## 7 <br />OWNER NAME �SUcy_'^n I�t� Pe L_ 1 PHONE <br />OWNER ADDRESS �J ` \L f t 1� O QCITY/STATE/ZIP l L r iY 1 J;�' 7 S Z !� <br />CONTRACTOR �NrT Cld l�Ofv(d'L�Y!1 C _ PHONE f -%l S�' 7/ <br />CONTRACTOR ADDRESS P. o 19 O 7'`' /2_3 CITY/STATE/ZIP e3�`"'^`�ti1 r <br />SUBCONTRACTOR <br />SUBCONTRACTOR ADDRESS <br />LICENSE r 57 r I C-61 1 D-09 fl Other <br />CITY/STATE/ZIP- <br />NUMBER ala 7 6 / <br />PHONE <br />EXPIRATION DATE. _t / 3 <br />GEOGRAPHICAL INFOR TION: Coordinates X Y Township _ Range Section <br />INTENDED USE omestic/Private Cl Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring U Soil Sampling/Characterization <br />I l Public Water System <br />If different from Owner: Water System Name —fit Name or Phone Number <br />TYPE OF WORK New Well I1 Replacement Well ❑ Well Alteration/Modification n Other <br />❑ Monitoring Well(s) # of wells <br />❑ Out -Of -Service Well <br />17 New Pump D Pump Replacement <br />WELL CONSTRUCTION <br />❑ Soil Boring(s) # of borings ❑ Geotechnical <br />LI Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />❑ Pump Repair tl Raise Well Casina <br /># of borings <br />Drilling Method ud Rotary ❑ Air Rotary � Auger ❑ Cable Tool u Push Point ❑ Other <br />Proposed Well Depth 3 oto ft Excavation/L /� in diameter 71 Open Bottom Gravel Pack/Gravel Size in diameter <br />U Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter in Thickss/ uge/ASTM Sched �O U Steel 19 lastic ❑ Stainless Steel ❑ Other <br />Grout Seal Depth )t eat Cement (94 lb bag/5-f0 gal water) u/ Sand Cement sack mix/7 gal water <br />I Bentonites 000 e?71 Other <br />Grout Placement Method - umped :1 Free Fall G Other U Retardant / Accelerator (name) <br />PEDESTAL Installed By ❑ Driller ump Contractor ❑ Other <br />Concrete Pedestal F'Dimensions: Width ft Length ft Thick in ❑ Christy Box fl Stove Pipe <br />PUMP F Submersible r 1 Turbine I1 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 I AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATION <br />MINIM 4 HOU DVA E OTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />SIGNED TITLE U "" -� DATE1I L 2- L6 <br />DEPARTMENT USE ONLY <br />Application Accepted By Date <br />Grout Inspection By Date <br />Date <br />Pump Inspection By <br />Soil Boring Inspection By <br />AMEDITS _ kl CLL�L 'ti <br />Date <br />to <br />D <br />v <br />M <br />M <br />M <br />ur <br />y <br />p r <br />Area 3 l Employee ID# 'tA&I 104 <br />❑ SPECIAL Well Permit <br />❑ WAIVER Received <br />Constructed Well Depth <br />ft <br />PE <br />Codes <br />Sc <br />Info <br />Received <br />B <br /><SD <br />ash <br />Amount Date <br />Remitted <br />Permit/ <br />Service Request # <br />Invoice # <br />Well ID# <br />3�i <br />/c5 <br />3-41011 1� 3 �� <br />R >, 63 D 6 <br />INl!" X53 � <br />EHD 43-06 <br />4/30/12 WELL /PUMP PERMIT <br />