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, q4' <br />V <br />Z,', u,,k �► 6-1- 110 DL'"�-- <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NUN -REFUNDABLE P/ER/VM�'IT /f � /ALyL"� 209 953-7697 FOR INSPECTIONS CEX%PIR/E�Sj%I YEAR <br />`/FROM DATE <br />� ISSS/UUED <br />JOB ADDRESS I �• L�`/�5� o " � r / Ir ( Q� CITY21P ty J Way, I `c/ J z <br />CROSS STREET 'r11U'� AAP,IN///t� Z�'1�Y !01 t PARCEL SIzE ' Z 7 LAND USE IAP(/P)ILICATIIOnN ##+ <br />OWNER NAME Maor'� <br />I V ��7 V / t/�� /�/P/El�/HON // " I/V��u�Y/�Ur ! 7 r/ • O <br />OWNER ADORE55 /_ S G t CITU TATNLI D- r <br />317 I> <br />CONTRACTOR `-"� ]"�IJ'/''C [)�JPHON �j CONTRACTOR ADDRES,St`/ {. CITYISTATEfZ — ��1 -/yt� <br />SUBCONTRACTOR ' • //��t �P//HON�EE 1 - <br />SUBCONTRACTOR ADDRESS / r CITU//1S�TnAT/EB/ZIP • ' I I <br />LICENSE C-57 -61 D-09 Other NUMBER EXPIRATION DATE <br />3EOGRAPHICAL INF MATION: Coordinates X Y Township Range Section_ <br />NTENDED USE V Domestic/Private Irrigation/Agricultural Industrial Water Quality Monitoring Soil Sampling/Characterization <br />Public Water System <br />If different from OwnerWa er bYSIem Name C.It.ct N—e or Phom um. er <br />TYPE OF VI''ORK New well Repiacement Well Well Alteration/Modification Other <br />Monitoring Well(�s��)�#of wells SoilBoring(s) #ofbonngs Geotechnical #ofbonngs <br />Out -Of -Service 0" Out -Of -Service Well Renewal Cross -Connection Repair <br />New F'Um ► flump Keplacement Nump Ke air 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 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 ft Thick in Christy Box Stove Pipe <br />i It <br />PUMP ubmersible Turbine Other HP Pump Set ft Standing Water Level j 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 CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATION LAWS. Q <br />SIGNED <br />MINIM}dM 24 HOUR ADVANC.E NOTICE REQUIRED FOS INSPECTIONS - PLEASE CALL 209 9 r7697 <br />10 I . <br />I■■■■■■■■■■■■rT <br />■■■■■■■■■■■■■■� <br />�-i <br />LA <br />g <br />M <br />N <br />`1 <br />S <br />11 <br />y 3 .1 2010 <br />_ DITAL HEALTH <br />r l.' ._. _ <br />RE�� yNo <br />JUAt 0 2016 <br />SANJOAQU <br />E 0"QlZAN 06lW V-rAL r <br />DEPARTMENT USE/ ONLY _ f. <br />Application Accepted By Date 61t(h' Area G Employee ID# <br />Grout Inspection By Date SPECIAL Well Permit <br />Pump Inspection ByiI DateaA WAIVER Received <br />Soil Boring Inspect'`4n By Date Constructed Well Depth ft <br />COMMENTS �G/ 3/ f �r �5 <br />"'" Invoice # Well ID# <br />Codes Info B as Remitted Service Re uest # <br />59do7ilcit,s I WP(X3q03 <br />EHD 4; -Ob <br />L3u12 <br />WELL /PUMP PERMIT <br />