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bb WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT 1866 East Hazelton Avenue - STOCKTON CA 952054232 - (209) 468.3420 <br />NON-REFUNDABLE PERMIT %Al l /Onol 0aa_,7e.,-, --- --- _ <br />JoesSTess 16220 N. CLEMENTS Rn . CITY2IP LODT 95240 <br />GROSS SYr�lGfiT pArtcEL 5rZE <br />-;;AO UBL APPLICA17ON # <br />OWNER NAME _("AT.TFnRNTA RA1Vf'FTANn TRi1,ST 'j�Q� Y�\�\ PHONk <br />9.16-4.4.4-2096 <br />OWNER ADDRESS 22�r. Tj grpi CITY/$TAT@IZ1P�(''R1�MF.Nmn CA QSR1 <br />CONTRACTOR �g1 ta_ �tffiU SrP0CXm()N ARMATiTRF k M <br />OmOR ORKU, _2b9-466— 625 <br />CONTRACTOR ADDRvzs 646 -S. C ELWOrni4 Street <br />CITY/STATE/ZIP Stot:kton, CA 95203 <br />SUBCONTRACTOR <br />SUBCONTRACTOR ADDRESS PHONE <br />CITY/STATE/ZIP <br />LIcENsE ❑ C-67 I C -el ❑ D-08 0 Other <br />NutiAsw'i 724778 ExPIRA'noN DATE 0$/I k <br />2 <br />GEOGRAPHICAL INFORMATION: Coordinates X Y <br />N ED US To"Shiq Range Section <br />_ ❑ Domesdc/Private grtgagon/Agricultural ❑ Industrial 0 Water Quality Monitoring 08011 Sampling/Characterization <br />D Public Water System <br />If diftsrent from Owner, a ema <br />n one u r <br />TYPE- 0._-__ F_111103; ❑New Weil 0 Reptaoement Well 0 We(I Alteration/flRodiflcadon 0 Other <br />O Monftoring Well(d1)�` # at we(Is p SO(( Boring(s) # of borings "`�"""""' �.. <br />❑ Out -Of -Service Woll t? Geot®chnlcaf c <br />❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair CQ <br />0 New Pum um Re lacement 0 pum Repair ❑ Ralae Well Cast n �4P <br />WELL CONSTRUCTION <br />11 <br />Drilling Method 0 Mud Rotary O-Air'Rotary 11AugerAuger 0 Cable Tool 0 Push Point 0 Ot �O'�QU/N <br />Proposed Well Depth ft r Exoavation — In diameter 0 Open Bottom 0 Gravel Pack oravel &I/�R�r <br />0 Conductor Cas In diameter / Conductor Casing Depth i star <br />Casing <br />Well Casing Diameter ____ In Thickness/G3auge/ASTM Sched ft MENT <br />Grout Seal Depth ft 0 Neat Cement (94 lb bag/6-10 gal water) Steel Q PlastSa dl Ce eSinless Steel ❑Other <br />0 Bentonite (20% solids) ❑ Omer sack mW7 gal water <br />Grout Placement Method 0 Pumped 0 Free Fall 0 Othor------ —_. <br />❑ Retardant / Accelerator name -- <br />CWF—UTCWF—UTAL Installed By ❑Driller 0 Pump Contractor O Other <br />0 Concrete Pedestal 131mannrn.,n. wvw#k m <br />IIVMP0 ersible ❑ Turbine 0 Other HP �, Pum Set_ ? 9 4 ft Sian In Water Leve <br />I HEREBY CERTIFY THAT I HAVE PREPARED <br />JOAQUIN COUNTY ORDINANCES, STATE LAWTHIS APPUCA77ON AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br />S, AND RULES AND REGULATIONS. i ALSO CERTIFY THAT MY REQUIRE[! LICENSE IS <br />CURRENT AND ACTIVE WITH THE CALIFOCANTRACTOR8 STATE UCEN$E BOARD AND THAT .1 AM IN COMPLIANCE WITH ALL <br />WORKERS COMPEN8ATI0 WS. <br />APPlIcation Accepted sy <br />Grout Inspection By <br />Pump Inspection By <br />Soll Boring By <br />By <br />COMMENTS 1� Lv:ti.z <br />EHO 43.08 <br />8/04/08 <br />ADVANCE NOTICE REQUIRED FOR INSPECTIONS p <br />TITLE CFO DAT 1. 00 <br />,-..c n I 3 G U <br />Date <br />Date <br />Date <br />Data <br />Employee ID# <br />SPECIAL Well Permit <br />WAIVER Received <br />WELL /PUMP PERMIT <br />tzt-V p <br />