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WELL 1 PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 31D FL-STOCKTON CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT -1 G CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS Z�2^I AWD �� 1 L] y 1�� f UEf..�IJ��.E CITY/ZIP���C.N(.TOV3 �S zz� <br /> CROSS STREETTQ� �U�h�11LE- _—APN 05-OqD I�, 1 1gPARCEL SIZE LAND USE APPLLICATIION# <br /> OWNER NAME ��.YT ,N. - PHONE 1A !>-1 `-ry <br /> Jo ZS <br /> p �/ •fit,. 'y i �j � <br /> OWNER ADDRESS •a+ P J� J (1� CITY/STATE/ZIP_51-0 -T; y 1 ,L 95 Z{ <br /> CONTRACTOR _W E I L (� /`a�rjbF-lV5t>l�,L} A' A.�3 OC.,J WTt S PHONE 3 6-1 � 3-1 b I ♦� <br /> CONTRACTOR ADDRESS 9 n x =I`J.i�1d&-r(z4 o W A� CITY/STATEIZIP 1r43ib I I �. 9 S 2A L3 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS /CI+T-Y/ST//A��TEIZ/IP r <br /> LICENSE C-57 11C-61 [3D-09 ❑Other NUMBER t0�7 V U`j EXPIRATION DATE `O JO <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE ❑Domestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring )iCJSoil Sampling/Characterization <br /> ❑Public Water System <br /> If different from Owner: Water System Nalne Contact Name or Phone Number <br /> C TYPE OF WORK 13 New Well .13 Replacement Well ❑Well Alteration/Modifi�io 4- INT2 <br /> ❑Monitoring Wcll(s) #of wells i]�,5oil Boring(.,) EXY., tEg--v­ <br /> 0 <br /> Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> ❑New Pum ❑Pump Replacement ❑Pump Repair Permit may have expired without <br /> WELL CONSTRUCTION work being comq)ieted or.inspected <br /> Drilling Method ❑Mud Rotary ❑Air Rotary [.Auger ❑Cable Tool 13.lush Point at e <br /> Proposed Well Depth (} <S _ft Excavation diameter ❑OpeottoitlViro rGiril']�P veR)Tf 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(941b hag/5-10 gal water) ❑Sand Cement sack mix/7 gal water <br /> ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name So IL. LLX'MFI�)l 5 ❑Specs on File fl Specs Submitted <br /> Grout Placement Method ❑Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) 14 <br /> PEDESTAL Installed By ❑Driller ❑Pump ContractorC}7 IlOiher ` <br /> ❑Concrete Pedestal Dimensions:Width ft Length ft Thick in [3 Christy Box ❑Stove Pipe <br /> PUMP ❑Submersible ❑Turbine ❑Other IIIJ Pump Set 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 CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> M NIMUM 24 HOUR ANCE NOTICE YQUIRED FOR INSPECTIONS -y l <br /> SIGNED TITLE tx ►`,p,4 I DATE <br /> O OB = :wPF 175-04 <br /> AVENUE -- <br /> a`a ®� •„® o ® �o� O <br /> �o <br /> a. •_-E�-.---VISTR p1 �OVENIIE --�ss N <br /> Bg fat Ie N '1 <br /> o ,y c <br /> C') MOSSWOOD PARK <br /> Lars 7Dr,rso-as-Dea7 �Q <br /> BeµE.l'•wa' <br /> saNA54&A tt1 NAD QTY <br /> IXi8 - 'I <br /> N-TjU S E O N-L-Y i <br /> Application Accepted B Date Area Employee ID# 1 F <br /> Grout Inspection By Date ❑ SPECIAL Wel) Permit 1 <br /> Pump Inspection By " Date ❑ ' WAIVER Received <br /> Constructed Well D P Pth ft <br /> l <br /> COMMENTS !J 7 <br /> f J <br /> PE SC Received Chec Amount ate Permit! <br /> Codes Into B Cash Remitted DService Request# <br /> *� Invoice# Well!D# <br /> Z- { C� 00 - <br /> EHD 43-02-006 WELL PUMP PERMIT <br /> 1/2712005 <br />