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WELUPUMP PERMIT <br /> SAN JOAOUIII COUNTY ENvinonmENTAL 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 /> JOB ADDRESS *P1 <br /> G' l 1( CITY2IP�rTJ�z N i�l-1� D <br /> CROSSSTREET APN 1 /•�/`w '-� PARCEL S¢E/ t 7 ANO USE APP(L�ICAT�1; 2 <br /> 011# p <br /> 1 PNONE6A,"_C(C�I ,2,V( <br /> 01'nIflR NAI,IE <br /> OVINER ADDRESS /. CITY/STATFJZIP <br /> CONTRACTOR , t V G`. I ) PHONE <br /> L ! <br /> CONTRACTOR ADDRESS �- CRY/STATF1711P�.V 4�'[;�L���Y"/ (� .' JSLI <br /> SUBCONTRACTOR IrN PHONE�j_ <br /> SUSCONTRACTOA ADDRESS CrrrY/STAT&71P N / <br /> LICENSE -67 �C-61 D-09 J Othef Nween r�G(� °K EXPIRATION DATE 3& I If' <br /> GEGORAPHICAL INFORMATIGII: Coordinates X Y Township_ Range_ Section_ <br /> INTENDED USE _p OmestictPrivate _IrrigaliONAgricultural C Industrial 7 Water Quality Monitoring Soil Sampl'ng/Characterization <br /> Public Weser System <br /> Ildeefent Nomwm r, a!eys m n meo on .0 r <br /> TYPE OF WORK Xyew Well XReplacementWen L Well AHeratiorVMod,fption J Other <br /> G Monitoring Well(S) #o(w•ells C Soil Bonng(s) s of Godnga 7 Geotechnical 0 of wIrgs <br /> ' J / Out-Of-Service Well r Out-Of-Service Well Rene•.val -1 Cross-Connection Repair <br /> New Pum �Pum Replacement L Pum Re ;r _1 Raise Well casing <br /> WELL CONSTRUCImN <br /> lathed:Mud Rot 'Alr Rosary -Auger' -l�Cable Tool -Push Pant Omer <br /> Proposed WdI Depth H Excavation in diameter Open Bottom -Gravel Pack/Gravel Size in diameter <br /> ConductP asing in diameter I Contlyc r Ing Depth l� H -1-{� ' <br /> /l iameler-S[/ in ickness/Gauge/ASTM Schell r Steel )(Plastic Sta'nless Stel Other <br /> 2 V Grout Seal OEl. ocl <br /> Neal Cement(941b bag16-10 gal roarer) _ - gal water <br /> lonite(20%solids) Other <br /> /A9 1 Grout Placement umped =Free Fell _Other Z Retardant/Acce'eralor(name) <br /> 1L/,�I// PEDEeTAL Installed Blr , r tier =Pump ConI,- Other <br /> Concrete Pedestal-Dlmenslonr Wdth (- H LeNth N Thick in -Christy Box I Stove Pipe <br /> Sulxnersbtel Turbine 'Olhat HP Pump Sot IT Standing Water Level (I <br /> I HER4CIRPT �INHAVIE PR PARED THIS APPLICATION AND THAT THE A'lORK WILL BE DONE IN ACCORDANCE VJITM SAN <br /> JOAOES,SELAWS,AND RULES AND REGULATIONS. I ALSO CERTIFY THAT RAY REQUIRED LICENSE IS <br /> CURRRH TH ALIF RNIA CONTRACTORS STATE LICENSE BOARD ANO THAT t Af.1 IN COI.IPLIANCE WITH ALL <br /> WORKLAW <br /> TIC D FOR IN!P C ZIPS_-PJ.EASE CALL(209 9 3.7693 <br /> SIGNED TITLE " `I DATE �I�___ <br /> a!l a4 <br /> ECIV=® <br /> Ti <br /> IL <br /> 62016 <br /> AlV1R�A' lENTAL HEALTH <br /> PERMIT/SERVICES <br /> P 411TRIE NT USE NLY yj/�/,,, ��HH KK <br /> ` OVw� <br /> Application Accepted ate Area Empbyee 10 <br /> Grout Inspeclio Date G SPECIAL Well Permit <br /> Pump Inspection By Uate C WAIVER Recelved <br /> Soil Boring Inspection By DateConstructed Well Depth H <br /> COMMENTS <br /> __Tv _Z. � _ � S r6.ft�-(ice► <br /> PE Sc Received Checks/ Amount PermIt" <br /> Codes Info B Cash Rsmlttad Dale Service R uest If Invoice 0 Well In,; <br /> V 14 <br /> W37 U3 }13�� 0 0 Y�ft� <br /> END4}M l:£LL IPU VP FEfn!1{ <br /> 4 C 2 <br /> s -7�,b51 <br /> ThDF qq T cVti�Y <br /> TENT <br />