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WELL/PUMP PERMIT 2-6YAW5-00�k 0 `00( ) W, <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 EAST MAIN STREET-STOCKTON CA 95202 - (209)468-3420 <br /> NOK`.+REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 'I YEAR FROM DATE ISSUED <br /> LP <br /> �„„ � n <br /> JOB ADDRESS �� �(�(� S t tIC1L }� C U CITY/ZIP L-�t�OP �5 3�� m <br /> CROSS STREET 1 f wK-s�lj f APN (C�(-10 _PARCEL SIZE ,-7P) LAND USE APPLICATION# <br /> N <br /> OWNER NAME �t� S -1 L llfk-z ?LA7 A PHONE y <br /> OWNER ADDRESS I S GOC7 S NASI fr>-1 CITY/STATE/ZIPt� �LC��M3Q <br /> CONTRACTOR V-Lrg6yY-� 'b"�Cfe �PHONE �Zy� <br /> ' <br /> l <br /> CONTRACTOR ADDRESS 7.LY�l di (! - 1 2 PO6p-�'k So 1]�c 1 bC� CITY/STATE/ZIP �I��b� CA, .Q5j0(D <br /> SUBCONTRACTOR M fl O;�LAE '/eey7q14 4- <br /> yen 7 h SiM PHONE 7 11 613 1J 0 <br /> SUBCONTRACTOR ADDRESS 9 +�"7 �, L V-VA0Ik S 1 ccCIT�Y/STATE/ZIP`�L, CA -S?'?'? (,? <br /> LICENSE C-57 I I C-61 I D-09 I I Other NUMBER 5p 19 � \ EXPIRATION DATE 3&2 11 <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE L Domestic/ i tfirrItupLaJ1,1 lg utri I l Water Quality Monitoring XSoil Sampling/Characterization <br /> I Public <br /> If different fr OIII V I I Ia Alpm Pfle I LLJ ContactName or Phone Number <br /> TYPE OF WORK 1 1 New Well �$ cEt ryVVerj <br /> Qraigq/�gfification Other 2 <br /> I Monitoring1 � iln►11 s111 R!{) #of borings VGeotechnical #of borings <br /> I I Out-Of-Serv� h—"-'+� eW enewal _I Cross-Con'n`ection Repair PAYMENT <br /> Li New Pum L' Raise Well Casing RE <br /> WELL CONSTRUCTION <br /> Drilling Method`^ud Rotary I I Air Rotary I I Auger I I Cable Tool .push Point I I Other <br /> Zx <br /> Proposed Well Depth '-5(D ft Excavation in diameters \1-1 Open Bottom I I Gravel Pack/Gravel SizeN''0AQQ in meter <br /> I Conductor Casing in diameter / Conductor Casing Depth ft 14 rh of if , <br /> Well Casing Diameter_ in Thickness/Gauge/ASTM Sched Steel I I Plastic I Stainless Steel U Other <br /> Grout Seal Depth 'c5O ft )QNeat Cement(94 lb bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water <br /> Bentonite(20%solids) ui Other <br /> Grout Placement Method Pumped i_ Free Fall _i Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller !_ Pump Contractor L� Other <br /> Concrete Pedestal Dimensions:Width ft Length ft Thick in 1-1 Christy Box a Stove Pipe <br /> PUMP Submersible I Turbine I I 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 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS �7 ^ /l <br /> SIGNED �� �� (ClAeK. (��b"O4ITLE A4b"Pr PA-1AG-v DATE / /pC� ( lu <br /> I <br /> r <br /> i' <br /> III�I <br /> H - <br /> b <br /> t <br /> H-4 <br /> DEPARTMENT USE ONLY <br /> Application Accepted By "� - Date �1-'31 ('-5- Area ` _ 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 Received Check#/ Amount Date Permit) Invoice# Well ID# <br /> Codes Info B Cash Remitted Service Re uest# <br /> EHD 43-06 WELL/PUMP PERMIT <br /> 8/04/08 <br />