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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 /> to <br /> 1cc� A qS <br /> JOB ADDRESS 1 V� ��-� � 1/ CInIZIv 1 , CD <br /> CROSS STREET I v C'``� 1 '1 1/ APN PARCEL SIZE ( - )�LAND USE APPUCA nON# m <br /> OWNER NAME c, U fy�+( C /IC, PHONE / w <br /> OWNER ADDRESS `,� L /�(_-/✓/[./"K "' vet y'V/a 7T CITY/STATE/7JP ` y �`/'�I <br /> CONTRACTOR \1)`)' 1n 1 r-C7,D, ) 1 n C 1 l PHONE ,CI _�G7{ 79 S7 <br /> CONTRACTOR ADDRESS 1 v '`J�I n I CITY/STATE/LP l �1`A I C A 1 5 G 3✓' <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITYISTATE/ZIP <br /> LICENSE C-57 C-61 D-09 Othef NUMBER I �S EXPIRATION DATE 7_:3 <br /> 1, J 1L <br /> GEOGRAPHICAL INFORMATON: Coordinates X Y Township_ Range Section_ <br /> INTENDED USE Domestic(Pnvate Imgation/Agricultural Industrial - Water Quality Monitoring Soil Sampling/Characterization <br /> Public Water System <br /> If different from Ownar. Water System Name ­taot Name or rro u <br /> TYPE OF WORK New Well Replacement Well Well Alteration/Modification Other <br /> Monitoring Wells) #of wells Soil Bonng(s) #of borings Geotechnical #of borings <br /> Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair <br /> _ New Pump XPumpReplacement _ Pump Repair XRaise 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 Cesing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter L in Thickness/Gauge/ASTM Sched &Steel D Plastic Stainless Steel Other <br /> Grout Seal Depth ft Neat Cement(94/b bag/5-10 gal water) ❑Sand Cement sack man 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 /> Concrete Pedestal Dimensions:Width ft Length It Thick in Christy Box Stove Pipe <br /> PUMP ubmersible Turbine Other HP PumpSet_. ft Standing Water Level s , ft <br /> 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 FO\RI INSPECTIONS-PLEASE CALL(209)953-769-77 <br /> SIGNED - L'I c 'i�-'L�~ TITLE `� 1C� �fCS,�r V1 DATE J / , ^' <br /> V <br /> W <br /> J <br /> G <br /> NOIf 1 0 UV <br /> vrfJ <br /> N 'trill U. <br /> L <br /> EP RTM ENT U-SE ONLY <br /> Application Accepted By /i Date �^ Area Employee ID#L�1 <br /> Grout Inspection By � Date 7 PECIAL Well Permit <br /> Pump Inspection By Date \ �r 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 Cash Remitted Service Request# <br /> lJ 7 `511X3/,` i93 '2 (- <br /> w 2E - ,X003 <<'t <br /> EHD 43-06 WELL/PUMP PERMIT <br /> 4130112 <br />