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i 7�+'tk S40n (1 '�j <br /> WELUPUMP 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 /> Joe ADDRESS C7 I I✓ H W y K' CITY/ZIP 95,73() <br /> m <br /> n <br /> 1 J j o0 <br /> CROSS STREET I�1 �� I�� 1 IR V APN J�"'T���-�"( PARCEL SIZE L/–XL>_LAND USE APPLICATION# m <br /> OWNER NAME �r <br /> (v/rr�\\ V `–` E _J '�11�C ILCCI �`� NONE 7 Y- I /y C. <br /> OWNER ADDRESS 1,� I\ V CRr( <br /> -'-Ci /C z\ <br /> CONTRACTOR ��C'1 I, y t� I 11Q� PHONE 7 1C'.CI n– �7 7G/I <br /> CONTRACTOR ADDREss P C' C'x t CITY/STATE/DP C- 0�' -"1 C�13 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITYISTATE/ZrP <br /> 7 <br /> LICENSE C-57 .0-61 _ D-09 _ Other NUMBER101 � -� E%PIRATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section <br /> INTENDED USE _Domeslic/Private )?,Inigation/AgnCuttural -Industrial Water Quality Monitoring -Soil Sampling/Characterization <br /> Pubic Water System <br /> I}diRerem f—Owner —' Contact Nam or ne u <br /> TYPE OF WORK New Well _-Replacement Well _. Well AlteratioNModifrcation Other <br /> -Monitoring Well(s) #Of wells Soil Bonng(s) S of bonngs Geotechnical s of bonrgs <br /> Out-Of-Service Well - Out-Of-Service Well Renewal Cross-Connection Repair <br /> New Pump Pump Replacement Pump Repair - Raise Well Casing <br /> WELL CONSTRUCTION _ <br /> Drilling Method Mud Rotary -Air Rotary Auger Cable Tool _ Push Point - Other I�d <br /> Proposed Well Depth C7(-,U ft ExcavationI--in diameter -Open Bottom )(Gravel Pack/Gravel Size_ diameter <br /> -Conductor/Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM SchedI�- -Steel X Plastic - Stainless Steel Other <br /> Grout Seal Depth ft Neat Cement(94 lb bag/5-10 gal water) Sand Cement IIC. J sack mixR gal water <br /> _:Bentonite(20%solids) Other <br /> Grout Placement Method XPumped _ Free Fall _. Other _. Retardant/Accelerator(name) <br /> TA Installed ByF4 --Driller _ Pump Contractor v Other <br /> Concrete edestal-Dimensions:Width 7 It Length ft Thick in -Christy Box :Stove Pipe <br /> PUMP Submersible" Turbine Other HP .r �� Pump Set ft Standing Water Level C- <br /> / 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- <br /> PCL`EA1"SECALL(209)953-7697 <br /> IF <br /> SIGNED TITLE 11 V DATE '1 7 <br /> \ 1� <br /> w J <br /> C <br /> PAY EENI Vi- <br /> : <br /> RECIVE <br /> DEC 2 ti 2� <br /> 3 <br /> JOAQVIN C o <br /> SAN VIHCMEN TAlri <br /> 7-1 <br /> HEAL H pEPAR <br /> lZ 9. <br /> D-EPARTMENT USE ONLY <br /> Application Accepted BDate -'� Area—���l` Employee ID#, L` <br /> Grout InspectDate l / :1 SPECIAL'Well Pernik <br /> Pump Inspection By �;) Date v 1 ` 1 r� 1 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 aah Remitted Service Requestill <br /> a2cC2k< <br /> EH043M /7l// / WELL/PUMP PERMIT <br />