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k � <br /> WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> ,-1 p rn <br /> 2 <br /> JOB ADDRESS t 6 2 I W �--0 Aae � CITY/ZIP Mf 71P Cg � / s -7 91, m <br /> D <br /> CROSS STREET / O <br /> /4 ti'b J ►''C W7ily APN y�Z� 1 Z � ��6 PARCEL SIZE �. ��,� USE APPLICATION# � <br /> .-LAND m <br /> T <br /> OWNER NAMEN�v�1e t'• SA,-JP/^ J PHONE A C� N <br /> OWNER ADDRESS 1.-I if ZIy) Lo A -5� � CITY/STATE/ZIP M , re LGi S33' <br /> CONTRACTOR Wes*i 6Q OL aki PHONE <br /> CONTRACTOR ADDRESS (�C 03 <br /> 3 3 CITY/STATE/ZIP CS C C Cn/I.'� A S3y� 1 <br /> $UEMCMTRAC�'r0~Ft�� J'r r Vt•%5, F e yyo+n.! I?p PHONE <br /> r�orSkwlT« tcit ers es b c,-^^ <br /> &t19C0ATRACTM ADDRESS (6 o o Pa S S Gt CITY/STATE/ZIP (", c, <br /> LICENSE C-57 C-61 D-09 Other NUMBER o ! / 6 EXPIRATION DATE <br /> O <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE Domestic/Private Irrigation/Agricultural Industrial Water Quality Monitoring Soil Sampling/Characterization <br /> Public Water System <br /> If different from Owner: Water System Name on ac ame or one Number <br /> TYPE OF WORK New Well Replacement Well Well Alteration/Modification i Other <br /> Monitoring Well(s) #of wells Soil Boring(s) #of borings Geotechnical #or borings <br /> Out-Of-Service Well Out-Of-Servi Well Renewal i Cross-Connection Repair <br /> New Pump Pump Replacement Pump Re ai A A J .Ii&isq Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary Air Rotary xAuger Cable Tool h Pus}h{P�oin n <br /> P p '�B <br /> Proposed Ytfe4F- Depth 14- rt'' `�'�ft Excavation in diamel!ep�le rarvel ack+/�G,rav a in diameter <br /> (3�✓'"a Conductor Casing in diameter / Conductor',/ i � eC�v�itI i(I <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched hi '} .- tel �$t �d Other <br /> Grout Seal Depth f-Nfl d'ptft �<Neat Cement(94 Ib bag/5-10 gal waferl Qnm�,] �d N;SD. ` sack mix/7 gal water <br /> Bentonite(20%solids) Other <br /> k;e <br /> Grout Placement Method Pumped Xree Fall YOtherT <br /> -rrwRe rdant/Accelerator(name) vl <br /> W <br /> PEDESTAL Installed By Driller Pump Contractor Other W <br /> N//4 Concrete Pedestal iDimensions:Width ft Length ft Thick in I Christy Box Stove Pipe <br /> PUMP ,vl H Submersible Turbine Other HP 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 /> MINIMUM 224 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br /> SIGNED / TITLE C�+V` l9'�f w DATE <br /> T <br /> s <br /> k <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date Y Area /`r1 Employee ID# <br /> Grout Inspection By Date SPECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Receivedheck# Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B as Remitted Service Request# <br /> EHD 43-06 WELL/PUMP PERMIT <br /> 4/30/12 <br />