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WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 488.3420 <br />ALL 963-7697 FOR INSPECTIONS 1 YEAR FROM ISSUED <br />NON-REFUNDABLE PERMIT CALL <br />Sc ReceivedChec <br />Info By <br />1209 }EXPIRES {DATE <br />,IVV 7 <br />permit' <br />Date Invoice # Well ID# <br />Service Request # <br />JOB ADDRESSI 1i 10 CITY/7iP l%I�L/� I ✓ <br />,,��, <br />_}.. 1i p <br />CROSS STREET I f C�1,'./T� 1c \'JC 1� D APMOS l L� 0'j PARCEL SIZE • o LAND USE APPLICATION # <br />Iola o t'03 7 I-1 <br />� PHONES <br />OWNER NAME �L� l �[.� 1 1 <br />(I,,I <br />OWNER ADDRESSI� CITY/STATE/ZIP "i <br />` y� <br />I "1 <br />CONTRACTOR L I /V PHONE <br />WP0677417 <br />��/7z/ <br />�%�a[ 3 <br />% � <br />CONTRACTOR ADDRESS CITY/STATE/ZIPV/ s� ';],. <br />SUBCONTRACTOR PHONE <br />SUBCONTRACTOR ADDRESS CRY/STATTEIZIPP <br />Q <br />` <br />LICENSE C-57 X C-61 __ D-09 Other NUMBER v v EXPIRATioN DATE V <br />GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section <br />INTENDED USE <DomesticlPrivate - Irrigation/Agricultural Industrial Water Quality Monitoring G Soil Sampling/Characterization <br />7. Public Water System <br />If different from Owner Water 5yste. Nome o" or Phone NUMtW <br />TYPE OF WORK >0ew Well Z Replacement Well _ Well Alteration/Modification �i Other <br />Monitoring Well(s) # of wells - Soil Boring(s) a of honrgs Geotechnical x or mnngs <br />-' Out -Of -Service Well Out -Of -Service Well Renewal - Cross -Connection Repair <br />Drilling Method ' \ Mud Rotatryr Air Rotary Auger - Cable Tool Push Point Other _ <br />Proposed Well Depth &6 ft Excavation _�— in diameter - Open Bottom 'yt' Gravel PaddGravel Size in diameter <br />Conductor Casing in diameter / Conductor Casing Depth ' ` it <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched( �- Steel Plastic Stainless Steel Other <br />Grout Seal Depth it Neat Cement (94 Ib bagl&10 gal water) Sand Cementl tl._sack mixl7 gal water <br />Bentonite (20% solids) _ Other <br />Grout Placement Method X --,Pumped Free Fall a Other Retardant / Accelerator (name) <br />PEDESTAL Installed By Driller Pump Contrecto Other <br />oncrete Pedestal 'Dimensions: Width ft Length ft Thick in Christy Box -Stove Pipe <br />PUMP Submersible- Turbine Other HPTt2E Pump Set_j= 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 I AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATION LAWS. <br />MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FQR INSPECTIONS PLEASE CALL (209) 953-7697 <br />- DEPARTMENT USE ONLY <br />Application Accepted By L' Date I to <br />Grout Inspection By Date �1 <br />Pump Inspection By bate j <br />Soil Boring Insoeyctlon By Date <br />COMMENTS 't r?� �n S ' t I - r„ 1 <br />Area Q A I l2 I EmployeeID#{�t� V Y <br />D SPECIAL Well Permit v <br />J WAIVER Received <br />Constructed Weil Depth — <br />P`(' p�'g <br />PE <br />Codes <br />Sc ReceivedChec <br />Info By <br />Amount <br />Cash Remitted <br />permit' <br />Date Invoice # Well ID# <br />Service Request # <br />p 2 <br />Iola o t'03 7 I-1 <br />43tik <br />g <br />WP0677417 <br />HD43-06 A -1 <br />- 1 V �/ VfV QV�3 ��i 1 WELLIPUMPPERMIT <br />4 <br />��g� .dv <br />