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6 <br /> WELUPUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)461-3420 <br /> NON-REFUMDAsLE PERMIT CALL 209 953-7697 FOR INSPECnous EXPIRES 1 YEAR FROM DATE ISSUED <br /> N <br /> JaB AtXttiEss L1T1r1DP 'L <br /> �y )/� ppa <br /> CROSS STREET r % APN ()0.7- /,7 0-7& PARCEL S� usE APPucAnON# A <br /> J / I ` m <br /> / 1 C /t 11 m <br /> OWNER NAME <br /> OWNER ADORES3 Z // l_N Cny/STATERIP <br /> Comm <br /> ACTOR Y PHONE • 'D <br /> �) FlZI64:5 y <br /> CONTRACTOR ADDRESS ' � � v � L CrtYl57aiP 0 i <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR REBS CRY/STATErbp <br /> LICE NaE C-57 n C-61 ri D-09 n Other NUMBER ' ExPntAT10N DATE <br /> GEO6aAPnaG1 N: Coordinates X Y Township_ Range Section_ <br /> (NTItNOeo WE esddPdvate C Irrigation/Agriculture) U Industrial D_Water Quality Monitoring J Soil SamplingfChwactedzation <br /> L Public Water System <br /> IrdiBercnt honlOwnuc nna ns NufnD@r <br /> TYPE Or Wow GKNew Wel ]Replacement Wel C WaU Alteration(Modlication Ci Other <br /> er a d�� <br /> r,Monitoring Wells) #of wells r Soil Bortns W endo g(s) res Geotechnical ¢s <br /> f'E <br /> Out-O(-Service Wel C Out-Of-ServiceWil Renewsl O Croas-Connection Repair *. <br /> U New Pran J Pum RB ent C Pum Repair D Raise Well Casing v °l <br /> gam,. <br /> WELL CONSTRUCTION <br /> Drilling Method ❑Mud Rotary J Air Rotary L Auger 3 Ca01e Tool G Pusb/Pzlnt <- Other 201 <br /> Proposed Well Depth It Evca ation��in diameter S Open Bolom _l Gravel PacidGravel Size �{ <br /> U Condector Casing in diameter / Cend sing Oep fl <br /> Wen Casing Diameter '}, in ThrdmessfGaugWASTM Srhed reel r t Plastic n Stainless Steel n Other ryqIV j�7y <br /> Grout Sul Deplh_LW It ❑Neat Cement(941D bag/5-10 gal wafer) G/Sand Cement �J sock mall gel wBt � R <br /> J Bentonite(20%solids) U Other FNT <br /> Grout Placement Method U Pumped 7 Free Fal D Other -Retardant/Aecaiarator(name) <br /> sTAL Installod By filer n Pump Contractor n Other <br /> t Co rob Pedesis)nDImenalons:Width ft Length R Thick in Christy Box 1 Seow Pips <br /> Ff M PISuDrrrersiWoU Turbine O Other HP Pump Sat n Standing W-dar Level rt <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 W" THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMP SAlTtMLAWS. <br /> MINI OUR ADVANCE NOTICE REQUIRED FO_ SPECTIONS-PLEASE CALL(209}953- 697 <br /> SIGLIED, * 7tTIF DATE / '• t <br /> - d <br /> )7 <br /> 1 <br /> PAe M E N T U O L <br /> Application Acceptall By 4A �..'Ana Employee ID#J� ���,,, � <br /> f <br /> Grout Inspection By Date C3 PEC WSII Permit (( <br /> Pump inspection By to r C1 WAIVER Received -y <br /> Soil acting Inspection By Date T__ Con cted Wel O�pth n <br /> COMMENTS Cl f ^ <br /> PE SC Rae hoelW Amount Data Pormw invoice# Well IDN <br /> Codes Info Guh R#mitfeq 39rWA # <br /> L4 2q <br /> cq <br /> wa 1/PUIP PHtMfT <br /> erD4lUe <br /> 4nar,2 Z 3�,o926 ' Salo SU <br />