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RECEIVED <br />MAY 2 9 2018 <br />WELUPUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELToN AVENUE - STOCKTON c L4Q Q N -I-A L I I E A L I I -I <br />NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM D4jkW TNI E NT <br />I HEREBY CERWITH CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE 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 />MINIMIJIM 24 ANCE NOTICE REQUIRE=0R1 CTIONS -PLEASE CALL (209) 953 -SIGNED TIQ�/1 .�.� DATE <br />Application Accepted By <br />Grout Inspection By <br />Pump Inspection By <br />Soil Boring Inspection By <br />COMMENTS <br />5 <br />ckl <br />V <br />9 <br />S <br />5' <br />S% <br />it 01 a& Ca 573 I <br />JOB ADDRESS <br />D C.MP , 1 r W <br />/ - de PARCEL USE APP # <br />CROSS STREETI6 <br />OWNER NAME <br />APN SIZE LAND LK: TION <br />�J���W01 <br />(^% <br />PHONE <br />y1y0 ',�`l A 2 ;VO4 <br />O O �45 <br />OWNER ADDRESS <br />U W V )' i CITY/STATE/LP 01 <br />G- <br />/�� �,/J <br />Ai O <br />CONTRACTOR <br />U PHONE <br />2 a <br />,-A 2101-- <br />CONTRACTOR ADDRESS J CITY/STATEZP�* * C ' C5 <br />SUBCONTRACTOR <br />N l' PHONE <br />SUBCONTRACTOR <br />ADDRESS CITY/STATE/zip <br />LICENSE <br />57 1 D-09 Other NUMBER21& ALL EXPIRATioN DATE:21 Iq <br />GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section_ <br />INTENDED USE <br />omesticJPrivate Irrigation/Agricultural Industrial Water Quality Monitoring Soil Sampling/Characterization <br />Public Water System <br />It dinererd from Owner: WatW NSM a umber <br />TYPE OF WORN <br />New Well Replacement Well Well Aiteration/Modification Other <br />MonitoringWell(s) #of wells SoilBoring(s) #otnodngs Geotechnical #ofbonngs <br />Out -Of -Service Well Out -Of -Service Well Renewal Cross -Connection Repair <br />New Pump )(.Pump Replacement Pump Repair Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method <br />Mud Rotary Air Rotary Auger Cable Tod Push Point Other <br />Proposed Well <br />Depth ft Excavation in diameter Open Bottom Gravel Pack/Gravei Size in diameter <br />Conductor Casing in diameter / Conductor Casing Depth It <br />Well Casing <br />Diameter _ in Thickness/Gauge/ASTM Sched Steel Plastic Stainless Steel Other <br />Grout Seal <br />Depth ft Neat Cement (94 Ib bay5-10 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 <br />Installed By Driller Pump Contractor Other <br />Concrete Pedestal Dimensions: Width It Length It Thick in Christy Box Stove Pipe <br />PUMP <br />ulxnersible Turbine Other HP Pump Set ft Standing Water Level= It <br />I HEREBY CERWITH CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE 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 />MINIMIJIM 24 ANCE NOTICE REQUIRE=0R1 CTIONS -PLEASE CALL (209) 953 -SIGNED TIQ�/1 .�.� DATE <br />Application Accepted By <br />Grout Inspection By <br />Pump Inspection By <br />Soil Boring Inspection By <br />COMMENTS <br />5 <br />ckl <br />V <br />9 <br />S <br />5' <br />S% <br />