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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)4683420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTION EXPIRES 1 YEAR FROM DATE ISSUED <br /> v Fie Y-� ''rs1 LA <br /> JOB ADDRESS �] CrrY/ZIP •v �� �� m <br /> CROSS STREET �• / N Zhu- 3SIZEg <br /> 1 �/ O PARCEL LAND USE/ppb PLICATION## <br /> OWNER NAME P N v P O/,NSE (�/') <br /> OWNER ADDRES D J�A/ ��( Q; / ` N C A P (VI —Ivy/vy� LL O 1 <br /> tj <br /> CONTRACTOR ) `tel F J cri ✓1� • / QPHONE C /U v/\ <br /> CONTRACTOR ADDRESS CITYISTAT _ S V� V <br /> SUBCONTRACTOR _ PHONE <br /> llSUBCONTRACTOR ADDRESS r• • • JITY/STATEMP // 1"�Y DA <br /> LICENSE C-57 C-61 0-09 Other__ NUMBER �i/7 ll){�I V EXPIRATION DATE L./ <br /> GEOGRAPHICAL INFO 0 <br /> ATION: Coordinates X Y Township_ Range Section <br /> INTENDED USE Public i Water <br /> Ste Imgation/Agricultural Industrial Water Quality Monitoring Soil Sampling/Characterization <br /> Public Water Syslem <br /> If different from Owner a er bystem r4ame ­—N—he or enore hivrnber <br /> i <br /> TYPE OF WORK New Well Replacement Well Well Alteration/Modification Other <br /> Monitoring Wells) #of wells Soil Boring(s) rt of borings #of bonngs <br /> Geotechnical <br /> Out-Of-Service W I piit-0f-Sonrica Well Renewa! Cross-Connection Repair <br /> New Pum Pum Re lacement Pum Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary Air Rotary Auger Cable Tool Push Point Other <br /> Proposed Well Depth ft Excavation in diameter Open Bottom Gravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Schad Steel Plastic Stainless Steel Other <br /> Grout Seal Depth ft Neat Cement(94 lb bag/5-10 gal water) Sand Cement sack mW7 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method Pumped Free Fall . Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller Pump Contractor Other <br /> ncrete Pedestal Dimensions:Width ft Length ft Thl In Christy Box Stove Pipe (1 <br /> PUMP Submersible Turbine Other HP Pump Set ft Standing Water Level Al 9 ft [� <br /> 1 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 v l <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 2 HOUR VANCE NOTICE REQUIRED FO(Q�`�fINSP/EEC�TI�pON/�S�-/PL,EAASE CALL(209)9 - 619J7 <br /> SIGNED TITLE J r _ V LSU// L lit j 1 DATE `L QP <br /> REce�Af T <br /> 46D <br /> Zulu <br /> �TMovr <br /> EIVED <br /> i L I I EH I f f!5 H 1 � 2016 <br /> DEP RTMENT USE NLY N�AE[yrAL HEALTH <br /> Application Accepted B , ate Area _ Employee ID# P CE <br /> Grout Inspection By Date�� SPECIAL Well Permit <br /> Pump Inspection By , Date_ �]J (( ItQ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth_ g <br /> COMMENTS <br /> PE SC ReceivedAmount Perm <br /> Codes Info B Cash Rwmitted Date Service Request# Invoice# Well ID# <br /> � s� a � �►JI 500 q INP 3 3�o <br /> EHD+we -- <br /> J,.G i2 WELL/PUMP PERMIT <br />