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I <br /> WELUPUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELToN AVENUE-STOCKTON CA 95205-(209)488-3420 <br /> NON-REFUNDABLE PERMIT � CALL 209 963-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS L l�•, SA,,4-- I\t',1. 1 c ( :� CITY/ZIP LC cA I Ci <br /> CROSS STREET «�>ti I—�M1 ) 1� APN /'v 5 1 4L) - 4 PARCEL SIZE <br /> 'I <br /> �OLANO USE/APPLICATION f <br /> OWNER NAME '� s fi PHONE <br /> OWNER ADDRESS //T[J CfTYISTATEIZIP {{ i <br /> CONTRACTOR 1= I PHONE _Jc�1 _"� 7`i <br /> CONTRACTOR ADORES 'G �6, Crrr/STATEIZIP V,I'}� C P S <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CrTY/STATPMP 7 <br /> LICENSE );C-57 C-61 D-09 Other NUMBER 9 3 EXPIRATION DATE 7- 3 1 _1 <br /> GEOGRAPHICAL INFORMATION: Coordinates Y Township_ Range Section_ <br /> INTENDED UBE sdc/P0We _InigationlAgriculNral :]Industrial Water Quality Monitoring _.Sol Sampling/Charectertzation <br /> PUNC Water System <br /> If diff erent from Owner — or <br /> TYPE OF WORK /4New Well =Replacement Well _Well Alteration(Modtfication Other <br /> =Monitoring Wells) M of wells =Sog Boring(s) I or nonnpe _Geotechnical s or borings <br /> Out-Of-Service Well -Out-Of-Service Well Renewal Cross-Connection Repair <br /> New Pump Pump Replacement =Pump Repair Raise Well Casim <br /> W BLL CONSTRucTON <br /> Drilling Method�"ud Rotary Air Rotary :- Auger 'Cable Tool _. Push Pont Other <br /> Proposed Well Depth 3C 5 R F_xcsvation _in diameter Open Bottom 7,Gravel Padc/Gravel Size /�I- In diameter <br /> Conductor Casing In diameter f Conductor Casing Depth R <br /> Well Casing Diameter In ThidrnessfGauge/ASTM Sched C I�Zi-) =Steel Plastic Stainless Steel -Other <br /> Grout Seal Depth CO R -Neat Cement(94 lb begJSTO gal water) Sand Cement I( S sack m&17 gal water <br /> _Bentonfte(20%solids) _Other <br /> Grout Placement Method umped _ Free Fag .,Other Retardant/Accelerator(name) <br /> E&2LIJ LInstalled By _ nl1er Pump Contractor Other <br /> Concrete Pedestal-Dimensions:WidthR Length R Thick in Christy Box Stove Pipe <br /> P Submersible-Turbine -Other HPC_ Pump S R Standing Water Level R <br /> 1 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 HOyf R ADVANCE NOTICE REQUIRED FOR INSPECTIONS- 1PLEASE CALL(209)963-7697 /x1 <br /> SIGNED /,,LLC n�'~.•, TITLE \I i •C1t Y) DATE <br /> / <br /> S <br /> I <br /> s <br /> PAYN► . <br /> cEI1101 <br /> RE <br /> SAN JONQUl <br /> R�,�VIRO <br /> HFp,1.TH o <br /> IE <br /> EP RTMENT U E 0 Y /� <br /> Application Accepted B Date Area Employee IDM YJL L�L�i <br /> Grout Inspection By A47i f_�a�- Date PECIAL Well Permit <br /> Pump Inspection By6Otr) Dateih 1 2'C 1 1°b ! WAIVER Received <br /> Soil Boring Inspection By Date Constructed Wed Depth R <br /> COMMENTS <br /> PE SC I Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Into BY Cash Remitted Service Request# <br /> P 4z <br /> 1 -r -, <br /> WELL/PUMP PERMIT <br /> iD <br /> 1432A 3 7-a <br />