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+ WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL ALTH DEPARTMENT 1868 EAST HAMILTON AVENUE-STOCKTON CA 95205-(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 537697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS U Q-7C"'It7S �G 1 on Q S3Zo ; <br /> ^' C O <br /> CROSS STREET APN O I�� PARCEL SQE O' / LAND USE�1PPLICD ON# <br /> rr a/nar 1- 0 e 1U7 _ L g y �tis <br /> OWNER NAME )) /�' t� PHONE <br /> OWNER ADDRESS /•')6 Ltin, <br /> �/ CITU TAT ZI �n / o <br /> CONTRACTOR f Lti , PHONE U <br /> CONTRACTOR ADDRESS V IA• r CITY/ T EIZIP _Tf/1r�) h <br /> � 15 0 <br /> SUBCONTRACTOR I PHHONEA S <br /> SUBCONTRACTOR ADDRESS .n CITY/STATE/ZIP I1 <br /> LICENSE C-57 �-61 D-09 Other Zt NUMBERL _(Q-(e EXPIRATION DATE <br /> GEOGRAPHICAL INFO ATKN1: 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 /> ttublict from Owner water Z5ySteM Name ContaCt Name or Phone Number <br /> TYPE OF WORK New Well Replacement Well Well Alteration/Modification Other <br /> Monitoring Well(s) #of wells Soil Boring(s) _ #of borings Geotechnical n of borings <br /> Out-Of-Service Well Out-Of-Service W Renewal Cross-Connection Repair <br /> New Pump Pump Replacement Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary Air Rotary Auger Cable Tool Push Point 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 Steel Plastic Stainless Steel Other (, <br /> Grout Seal Depth ft Neat Cement(94 lb beg15-10 gal water) Sand Cement sack mix/7 gal water Q <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 Le h ft Thick in Christy Box St ve Pipe <br /> PUMP Submersible Turbine Other HP Pump Set it Standing Water Level ft lQ J <br /> IN <br /> 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 _A <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL �^) <br /> WORKERS COMPENSATI WS. -- 1 <br /> MINIMUM 24 ADV CE ICE REQUIRED F07S E9TIO S-PLEA CALL(209)913 7697 <br /> SIGNED i'. TI >> V[,( DATE 77 11N <br /> r[ECEIVED <br /> JAN 292US <br /> RONMENTAL HEALTH <br /> REC��V ERMIT/SERVICES <br /> FEB 0 5 2 <br /> CiOVN� ARTMENT SE ONLY / <br /> �DAQU�N EN fAbva1; ton Accepted By Date S- Y Area`'�—� i— Employee ID# <br /> SPA NV`RD�PARZMENhrout Inspection By Date SPECIAL Well Permit <br /> H�`t Pump Inspection By , Datemiffin WAIVER Received <br /> Soil Boring Inspection By Date _ Constructed Well Depth It <br /> COMMENTS i + - <br /> C�tp „ u (L(FC. G Uu a 1't{v�1. <br /> PE SC Received CChec AmountDate Permit Invoice# Well ID# 1�++�1 04,iry <br /> Codes Info B h Remitted Service Request# <br /> q36i OSU s Pob Pkpq cit <br /> fit- 061b�lq <br />