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,7 <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 /> --IIII N <br /> JOB ADDRESS �. 13�'i -- C:R'�/l.. CITYIZIP Tracy, CA 95377 m <br /> D <br /> CROSS STREETAPN 23860027 PARCEL SIZE 20.24 LAND USE APPLICATION# m <br /> En <br /> OWNER NAME JT Storage (John '1 oste) PHONE (209) 481-9386 <br /> OWNER ADDRESS 2460 Toste Drive CITY/STATE/ZIP Tracy, CA 95377 <br /> CONTRACTOR RMA Geoscience, Inc. (Consultant) PHONE (559) 708-8865 <br /> CONTRACTOR ADDRESS 3897 N. Ann Avenue CITY/STATE/ZIP Fresno,CA 93727 <br /> SUBCONTRACTOR Hillside Geotechnical Drilling (Drilling Contractor) PHONE (209) 815-5440 <br /> SUBCONTRACTOR ADDRESS PO BOX 143 CITY/STATE/ZIP Tracy, CA 95378 <br /> LICENSE X C-57 Ll C-61 Li D-09 _1 Other NUMBER 800276 EXPIRATION DATE 6-30-2015 <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE ❑ Domestic/Private ❑ Irrigation/Agricultural i i Industrial ❑ Water Quality Monitoring K Soil Sampling/Characterization <br /> ❑ Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone NUMber <br /> TYPE OF WORK ❑ New Well ❑ Replacement Well ❑ Well Alteration/Modification LI Other <br /> ❑ Monitoring Well(s) #of wells t] Soil Boring #of borings s) XI Geotechnical 6 #of borings <br /> ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal Cl Cross-Connection Repair <br /> ❑ New Pum ❑ Pump Replacement ❑ Pump Repair m f 1 Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method i Mud Rotary i Air Rotary Auger ❑ Cable Tool ❑ PC oft M JOTe, sIN <br /> Proposed Well Depth ft Excavation in diameter Bottom Grav P /Gr I in diameter <br /> P P r' nib <br /> ❑ Conductor Casing in diameter / Conductor Cas�ri De,fQ(��/+}�,,�,t <br /> Well Casing Diameter in Thickness/Gauge/ASTM Schad kVd( n d�fS��a�Ssgt�L thtWer <br /> Grout Seal Depth See Plan ft X Neat Cement(94/b bag/5-10 gal r �1n�San��L+14Ntit Or InJ;f1AI+ti'n.tack mix/7 gal water <br /> 1 Bentonite(20%solids) ❑ Other nVirpnML1 <br /> Grout Placement Method i i Pumped XI Free Fall X Other Trem ie ❑ Retardant/Accelerator(name I7 <br /> PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other <br /> ❑ Concrete Pedestal❑Dimensions:Width ft Length It Thick in ❑ Christy Box ❑ Stove Pipe <br /> PUMP El Submersible LI Turbine i 1 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 /> UMADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL(209)Q953-7697 <br /> SIGN D';�% '- TITLE STAFF DATE ✓ _ 15 <br /> I_ CAI <br /> T <br /> D <br /> N 5 <br /> IV; <br /> /y 44 <br /> N7y <br /> ---TH-F.Pq _T I I I <br /> DEPARTMENT ;UrECat NLY <br /> Application Accepted By e t 5 t Area b 5JTV464.4 Employee ID# TIP L-OPI <br /> Grout Inspection By Date ❑ SPECIAL ell Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE Sc Received Check!/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info By Remitted Service Re uest# <br /> EHD 43-06 WELL/PUMP PERMIT <br /> 4/30/12 <br />