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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1668 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 /> 3QUg Teeeh4r RV cITY21P '� GC-Y'-�C'r a <br /> JOB ADDRESS p 1 'nC v 1 �� I m <br /> CROSS STREET` �aMS IOC(�/ ,`y /� D <br /> APN U O Sig I - Sl/-�-' PARCEL SIZE L LAND Ust Appuci TION S g <br /> OWNER NAME 'CG t 1 Y, o t' `-ems CPH`ONN E 1,/U VI/�/ -I/t,`..' ] a <br /> OWNER ADDRESS 17J2' ry- CITY/STATEZP ] 11.11..✓�( U, 1 .I..CI� <br /> CONTRACTOR VO�IIC \7J�t \"1,tf�� I PHOAE1 �( 1/�- ?(77 1 <br /> CONTRACTOR ADDRESS�. 9 C•A `i nr CITY/STATEZP L/�\11--C A <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATI)EIZIP <br /> LICENSE 1,C-57 Y%C-61 .'049 - Other NUMBER �C'CI l:J EXPIRAT10NDATE <br /> DOMESTIC WELLSAMPUNG: _General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) :Arsenic(4393) <br /> INTENDED USE {�Domestic/Private _ Irrigation/Agricultural Industrial Water Quality Monitoring - Soil Sampling/Characterization <br /> Public Water System <br /> If d.h—nt ft—Owner Water System Name Contact Name or Phone Number <br /> TYPE OF WORK 7 New Well - Replacement Well Well Aheration/Modification Other <br /> Monitoring Wells) #of wells Soil Bohng(s) a°I bwne' Geotechnical x ar Iwdnge <br /> Out-Of-Servrce Well Out-Of-Service Well Renewal E Cross-Connection Repair <br /> __ __ ------- --ne'Sii RYIaC vreri�"aiiiil- <br /> WELL CONSTRUCTION e <br /> Drilling Method >rMud Rotary Air Rotary -Auger rCable Tool -7 Push Point - Other <br /> Proposed Well Depth 7 ft Excavation in diameter Open Bottom S Gravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter I Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched 'ti Joy Steel ,Y Plastic _ Stainless Steel _ Other <br /> Grout Seal Depth ft Neat Cement(94 Ib bag/5-10 gat water) ,i Sand Cement _ sack mix/7 gal water <br /> Bentonite(20%solids) L Other <br /> Qm'-'t plarement Method K pumped 7 Gr.Fell Mhor - ReterAe�t I Arroler etnr/game\ <br /> PEDESTAL Installed By }- Driller ❑Pump Contractor Other <br /> P.Concrete Pedestal Dimensions:Width ft Length ft Thick in Christy Box Stove Pipe <br /> PUMP Submersible Turbine Other HP Pump Sel ft Standing Water Level 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 I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> H/../C i.DVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED /7 // cLlG r•- TITLE V Xe-Q. ?Y-CS t Citi Y1 T DATE <br /> I <br /> I <br /> n <br /> I <br /> PA_ TMENT UE NLY <br /> Application Accepted By to Area Employee ID#i <br /> Grout Inspection By Dete ESPECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC I Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Into Cash Remitted Service Re uest# <br /> Q 6 r <br /> b I. <br /> LHD 43-06 revised 4114118 493 <br /> Sal,33 WELL PUMP PERMIT <br />