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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 <br /> NON-REFUNDARhE PERMIT CAL 2 3-7697 FOR INSPECTION EX IRES 1 YEA FRO ATE ISSUED <br /> JOB ADDRESS • I a f Ica CITY P ri—rer <br /> D <br /> FINS!CROSS STREET APN - PARCEL SIZE LAND SE APPLICATION# o <br /> ear A <br /> �xir m <br /> '.OWNER NAME ivi L41 /� <br /> OWNER ADDREB lr G <br /> CONTRACTOR I 'V <br /> jPN EC <br /> CONTRACTOR ADORE 1 _`' CITY/STATE.' IP <br /> Girl <br /> SUBCONTRACTOR IV I PHQNF <br /> SUBCONTRACTOR ADDRESS GITY/134TATE0 �Nv/ <br /> LICENSE C-57 D-09 Other 2. <br /> NU E� � EXPIRATION DAT �• <br /> J 3112.b- <br /> DOMESTIC WELLS PUNG: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> IF <br /> INTENDED USE V DUmestic/Pnvate Irrigation/Agricultural Industrial Water Quality Monitoring Soil Sampling/Characterization <br /> Public Water System <br /> If deferent from Owner. Water System Name contact Name or Phone Number <br /> TYPE OF WORK New Well Replacement Well Well AlteratloniModification Other RZ <br /> Monitoring Well(s) #of wells Soil Bo,ing(si a df borings Geotechnical is of borings <br /> Out-Of-Service Out-Of-Service Well Renewal Cross-Connection Repair <br /> New Pump Pump Replacemen Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> I Drilling Method Mud Rotary Air Rotary Auger Calais Tool Push Point Other <br /> j Proposed Well Depth tt Excavation in diameter Open Bottom Gravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter I Conductor Cas:rg Depth ft <br /> j Well Casing Diameter_in ThicknessiGauge/ASTM Schad Steel Plastic Stainless Steel Other <br /> Grout Seal Depth ft Neat Cement(94 Ib bag/5-10 gat seater) Sand Cement sack mix/7 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 /> oncrete Pedestal Dimensions:Width_it Leng•. ft Thick in . Christy Box St P'pe <br /> PUMP Submersible Turbine Other HP Pump Set ft Standing Water Level ft <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND T AT 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 /> MIM MU 24,FiA DVANCE NOTICE REQUIRED FO INSPECTIONS-PLEASE CALL(209 95J-7 97 �^ <br /> SIGNE �I TITLE DATE CA <br /> i <br /> i <br /> _ l <br /> A 1 <br /> PA <br /> MAR <br /> JOANV�RONIN COUN <br /> Application Accepted By P R T Cate T E/p, N L Y Area TH OEPAR M NT 1' <br /> LYSE <br /> 41E.IAL <br /> Ployee IDGrou[Inspection By Date Well Permit <br /> Pump Inspection By Date `IAN WAIVER Received <br /> Soil Boning Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received C Amount PermiV <br /> Co s Info ash Remitted Date Service Re nest# Invoice# Well ID# <br /> 3 <br /> e�ea�.os dev�5 <br /> WELL/PUMP PERMIT <br />