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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 -REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> otil /NJ (/ �t / 7p��.t L y <br /> JOB ADDRESS ,,�(f� `" p 7c p CITY/ZIP <br /> ��' /� � '� b �� V � �v m <br /> CROSS STREET 9A /� fret /G7 APN 0 ?/— jZy CEL SIZE '• - , LAND USE APPLICATION # <br /> / // S. p A <br /> OWNER NAME ^ y �2rf� /7 � �rPHONE <br /> OWNER ADDRESS L VX " / CITYISTATEIZIP �/ <br /> CONTRACTOR �+ a4 O 4!^1 f ftO,r'{ 1644 d- (/ �✓"�//J PHO1/ONNE ` Z V �, 9 r� 777 <br /> CONTRACTOR ADDRESS Y�DO 'r SKI SIO fw !" efT CITY/STATE21P r l r0 �' �Y �'✓ 9-r <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CIN/STATE/ZIP <br /> LICENSE ': I C-57 61 D-09 I I Other NUMBER EXPIRATION DATE <br /> GEOGRAPHICAL INFORMATION : Coordinates X Y Township _ Range Section_ <br /> INTENDED USE omeslic/Private I i Irrigation/Agricultural - I Industrial I Water Quality Monitoring Soil Sampling/Characterization <br /> 1 Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK 1 New Well I Replacement Well ' ; Well Alteration/Modification Other <br /> MonitoringWell(s) # of wells SoilBoring(s) # ofborings Geotechnical of borings <br /> Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair <br /> New Pump 1 Pump Replacement Pump Repair Raise Well Casing <br /> WELL CONSTRU TION <br /> Drilling Method Mud Rotary I Air Rotary 1 Auger Cable Tool i Push Point Other <br /> Proposed Well Depth ft Excavation in diameter i 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 I ' Steel Plastic 1 Stainless Steel i Other. <br /> Grout Seal Depth ft Neat Cement (94 /b bag1540 gal water) Sand Cement sack mix/7 gal water <br /> Bentonite (20% solids) I Other <br /> Grout Placement Method I Pumped I Free Fall 1 Other Retardant / Accelerator (name) <br /> PEDESTAL Installed By - Driller '. I Pump Contractor 1 Other <br /> 1 Concrete Pedestal ' ] Dimensions: Width it Length It Thick in 1 Christy Box i Stove Pipe <br /> PUMP >o6ulomersible Turbine i Other HP Pump Set 2 'Yd ft Standing Water Level �Q 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 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS, <br /> MINIMUM 24 HOUR A rE OTICE REQUIRED FOR INSPECjIONS - PLEASE CALL (209) 953-7697 <br /> SIGNED TITLE l✓�9 � B ` �'r'" DATE 7 /0 7 <br /> EW <br /> fu 2017 <br /> COUNTY <br /> O MENTAL <br /> L N D _P RTMENl' <br /> Ep RTMENT YSE ONLY y /\ <br /> Application Accepted By Date Q% Area — L Employee ID# � !� <br /> Grout Inspection By Date ❑ PECIAL Well Permit <br /> Pump Inspection By , Date ❑ 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 Cash emitted Service Re uest # <br /> a <br /> EHD 43-06 WELL fPUNIP PERMIT <br /> 4130112 <br />