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WELL / PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3"D FL-STOCKTON CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE <br /> r�PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES <br /> I YEAR FROM DATE ISSUED <br /> JOB ADDRESS �"✓ 1� _oda CITY/ZIP GMF—\C1� ✓�� V <br /> V <br /> CROSS STREET \ 7Lr\ APN PARCEL SIZE _LAND USE APPLICATION# XCROSS STREET_T_ <br /> OWNER NAME PHONE 7 — �� 1 �cl K <br /> °Th1/I t, r�``'y � <br /> OWNER ADDRESS p I U1��I ` d1611 Isy° CITY/STATE/ZIP <br /> CONTRACTOR 1, IU t/�j� h,NA /�"I"'Vr, PHONE�y �►��/� l 1}�— ��7U <br /> CONTRACTOR ADDRESS `-"��lJ �M CITY/STATE/ZIP <br /> SUBCONTRACTOR PHONE \� <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE C-57 ❑C-61 ❑D-09 ❑Other NUMBER EXPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE Domestic/Private ❑irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization <br /> ❑Public Water System <br /> If different from Owner: Water System Name ontact Name or P one Number <br /> TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification ❑Other #of borings <br /> ❑Monitoring Well(s) #of wells ❑Soil Borings) #of borings 11 Geotechnical <br /> ❑Out-Of-Service Vll ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> ❑New Pump !APump R lacement ❑Pump Repair <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 Sched ❑Steel ❑Plastic ❑Stainless Steel ❑Other <br /> Grout Seal Depth ft ❑Neat Cement(94 lb bag/5-10 gal water) ❑Sand Cement sack mix/7 gal water <br /> ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted <br /> Grout Placement Method ❑Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑ Other <br /> ❑Concrete Pedestal Dimensions:Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe <br /> PUMP ubmersible ❑Turbine ❑Other HP Pump Set ft Standing Water Level ft <br /> I HEREBY CERT FY 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 /> CURREN ND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORICE S OMPENSATION LAWS. <br /> M IMUM 24 HOUR ADVANCE NOTIC REQUI FOR INSPECTIONS <br /> SIGNED TITLE DATE , <br /> -a <br /> 11 IV <br /> A <br /> � z <br /> DEP RTMENT US O LY <br /> Application Accepted By ate Area Employee ID# <br /> Grout Inspection i B Date ❑ SPECIAL Well Permit <br /> By <br /> Pump Inspection By. _� Daten/ 7�a /J�' ❑ WAIVER Received <br /> Constructed Well Depth ft <br /> COMMENTS �V.� 2E>r <br /> PE SC Received Chec Amount Date Permit/ Invoice# Well ID# <br /> Codes Info Rv Remitted Service Request# <br /> ibUb 7� <br /> WELL PUMP PERMIT <br /> EHD 43-02-006 <br /> 1/27/2005 <br />