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WELUPUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT <br />GALL 209 95 -769 <br />R INSPECTIONS <br />1 YEAR FROM UATE ISSUED <br />Amount <br />Remitted <br />Date <br />Permit/ <br />Service Request # <br />�EXPIIHES <br />Well ID# <br />JOB ADDRESS <br />CITY/ZIP !_ <br />livy4yA <br />CROSS STREET <br />— <br />PARCEL SIZE. l <br />LAND USE APPLICATION If <br />OWNER NAME <br />/1AP <br />4� <br />O <br />PHONE <br />P <br />1,C/ (3V <br />OWNER ADDRESISIV41 ADDRESS <br />OJIS TE/ZIP <br />�!J <br />CONTRACTOR <br />PHeONNE <br />L� <br />s6 <br />�J�� �6� <br />� a " <br />CONTRACTOR ADDRESS • <br />CITY/STATE/ZIP <br />WP w�/ <br />SUBCONTRACTOR <br />PHONE <br />SUBCONTRACTOR ADDRESS <br />CITY/STATE/ZIP <br />LICENSE C-57 C-61 <br />i I D-09 ❑ Other <br />NUMBER3,)'17C 7. <br />EXPIRATION DATE <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: Water System Name Contact Name or Phone Number <br />TYPE OF WORK ❑ New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other <br />❑ Monitoring Well(s) If of wells ❑ Soil Boring(s) # of borings ❑ Geotechnical <br />❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br /># of borings <br />New Pump i i Pump Replacement ❑ Pump Repair i i Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method ❑ Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point J Other <br />Proposed Well Depth ft Excavation in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel Size in diameter <br />❑ Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched ElSteel LlPlastic Li Stainless Steel ❑ Other <br />Grout Seal Depth ft ❑ Neat Cement (94 lb bag/5-10 gal water) ❑ Sand Cement 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 Driller ❑ Pump Contractor ❑ Other <br />Concrete Pedestal Dimensions: Width ft Length It Thick in ❑ Christy Box Stove Pipe <br />Pump XSubmersibleD Turbine ❑ Other HP L Pump Set__Lb ft 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 CALIF0 IA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WIT ALL <br />WORKERS COMPENSATION LAWS. <br />M M HOU TICE REQUIRED 170I1,WSP�CTIONS - PLEASE CALL (209) 95 769 <br />SIGNED TITLE V S DATE <br />P_A TMENSNLY <br />;�(wf <br />Application Accepted By DateS <br />Grout Inspection By Date I <br />1 <br />Pump Inspection By Date 1 <br />Soil Boring Inspection By Date <br />COMMENTS <br />Area iqqEmployee ID# W�M_ <br />F]SPECIAL Well Permit <br />❑ WAIVER Received <br />Constructed Well Depth ft <br />T <br />m <br />D <br />0 <br />0 <br />m <br />m <br />cn <br />m <br />PE <br />Codes <br />SC <br />Info <br />Received <br />B <br />Check#/ <br />Cash <br />Amount <br />Remitted <br />Date <br />Permit/ <br />Service Request # <br />Invoice # <br />Well ID# <br />EHD 43-06 WELL /PUMP PERMIT <br />4/30/12 <br />