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i 1 lig• <br /> WELLIPUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 96206-(209)468.3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED <br /> Jog ADDRESS 4 V �I G CITY/LP A as \Pb 952'M!' <br /> CROSS STREET ' S Mass 1,V• AP /� D PARCEL SIZE , 1 LAND USE APPLICATIGO�N 1' p� <br /> OWNER NAME 1• '�w —PHONE ^(' 1 51-290( w <br /> OWNER ADDRESS `� 1 Crrv1STATE/2AP I"" �I'r _ <br /> CONTRACTOR -'U'a I----�4 ■ l� ^�CI O JP. l PHONE _ 4 - r <br /> CONTRACTOR ADDRESS 4 nC .rFa CITY/STATE/LP Ir Ki <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CrTY/STATE/LP <br /> LICENSE C-57 C-61 0-09 Other NUMBER Pj3 EXPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section_ <br /> INTENDED USE Domestic/Pdvate _Inigation/Agricuttural 'Industrial 'Water Quality Monitoring -Sal Sampling/Characterization <br /> Public Water System <br /> It tliHereM from Owmc WCAf O— o ame or a um <br /> TYPE OF WORK New Well Replacement Well - Well Alteration/Modification Other <br /> Monitoring Well(s) #of wells - Soil Boring(s) s of bonrys Geotechnical s or bumps <br /> t-111-Service Well - Out-Of-Service Well Renewal Cross-Connection Repair <br /> New Pum Pum Replacement - Pum Repair ^Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method XMud Rotary Air Rotary -Auger Cable Tool Push Pant Other <br /> Proposed Well Depth ;X76_ft Excavation 1! in diameter Open Bottom ravel Pack/Gravel Size_l4 in Wameter <br /> Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter�in Thidmess/Gauge/ASTM Schad VhO— _j Steel )'Plastic -Stainless Steel Other <br /> Grout Seal Depth b_11 L Neat Cement(94 lb bag/5-10 gel water) )'Sand Cement (r),3 �jg2 sack mvK17 gal water <br /> .-Bentonite(20%solids) Other <br /> Grout Placement Method Pumped Free Fall Other Retardant/Accelerator(name) <br /> lawsTAI, I stalleDriier Pump Contractor Other <br /> Concreted By Waste, Dimensions:4Vldth_ ft Length It Thick in Christy Box Stove Pipe <br /> PSutxnersiWe-Turbine Other HP Pump Set ft Standing Water Level <br /> UMP 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 /> MINIMUM 24 HOYR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED /C9�c'f IC,�Z uilc� TITLE ViCIC �l'GS P 4 DATE <br /> W <br /> e <br /> I F <br /> I 1 <br /> RE <br /> I <br /> JO'Q�Iy,EItI <br /> SIA ,'0f� E ARTMENT SSE NLY �,� <br /> Application Accepted a Date O Area Employee lD �%4' [ l7 <br /> Grout Ins F Date I PECIAL Well Permit <br /> Pump Inspection By Data , I WAIVER ReoeiVed <br /> Soil Boring In 'on By Date Constructed Wall Depth it <br /> MENTS fC d/ 5 ` <br /> PE SC Recei ed Check#1 Amount PermiU <br /> Codes Info B Cash Remitted Data Service Ra west• Invoice S Well IDs <br /> tN 51 S RV T7 t�I ftOb b`1 <br /> r7 5 <br /> Pia! <br /> C <br /> EHD 43-06 WELL!PUMP PERMIT <br /> 4/30/12 (-? T6 <br />