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WELUPUMP PERMIT <br /> SAN JOAQU'4 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 /> JOB ADDRESS / ( ` • CITY/ZIP / /�L m <br /> ATD <br /> CROSS STREET 07- e APNNV V'7---PARCEL SIZE LAND USE APPLICATION# v <br /> OWNER NAME 'r PHONE 0 m L N <br /> OWNER ADDRESS (� / CITY/STATE/ZIP <br /> CONTRACTOR A � L`O X. I�-t L h. PHONE tJ 3 <br /> CONTRACTOR ADDRESS <br /> I 6 t?� CITY/STATE/ZIP <br /> SUBCONTRACTOR `i i rg fry lms r PHONE -3 -L—)-7 <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE 1-4Z-57 ' C-61 I D-09 Other NUMBER c EXPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE omestic/Private ' Irrigation/Agricultural I Industrial Water Quality Monitoring Soil Sampling/CharaC�jgp. <br /> Public Water System_ 7/�/� <br /> If different from Owner: Water System Name Contact Name or Phone um <br /> TYPE OF WORK eW Well Replacement Well Well Alteration/Modification Other nr 7. <br /> I� <br /> Monitoring Well(s) #of wells I Soil Boring(s) If of borings i Geotechnical� f�7 rir' �D <br /> O_XNut-Of-Service Plum Re lacement 1 Pump Re airce Well Renewal Raise Well CasinCross-Connection Repair �N�� COU v <br /> WELL CONSTRUCTIONPART <br /> Drilling Method Mud Rotary Air Rotary Auger Cable Tool Push Point Other MPNA <br /> Proposed Well Depthft Excavation 1'7— in diameter 1 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 Sched2,12 _ 1 1 Steel >6Iastic Stainless Steel Other <br /> Grout Seal Depth Neat Cement(94 Ib bag/5-10 gal water) Sand Cement '� sack miYJ7 gal water <br /> i Bentonite(20%solids) i Other <br /> Grout Placement Method Pumped Free Fall 1 Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By ><Driller i 1 Pump Contractor Other <br /> Concrete Pedestal Dimensions:Width_ ft Length It Thick in 1 Christy Box Stove Pipe <br /> PUMP %<Submersible Turbine 1 Other HP Pump Set 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 COMPENSATIO S. <br /> MINI MUN! ,H� AD ANCE NOTICE REQUIRED FOR INSPECTIONS- PLEASE CALL(209)953-7697 <br /> SIGNED TITLE ato„ DATE <br /> TV L <br /> Y p f <br /> NJ L <br /> C' I <br /> DE RTMENT USE ON <br /> Application Accepted By Ar Date o Lj Area Employee ID <br /> Grout Inspection By Date 1 ❑ SPECIAL Well Permll <br /> Pump Inspection By Date -1 WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth 3,5-5 ft <br /> COMMENTS A. <br /> PE SC Received QhQEW Amount Date Permit/ Invoice# Well ID# <br /> Codes Info By Cash Remitted Service Request# <br /> ky, <br /> St -µRyy.. � <br /> 430 2/�� I�z�� � 7D WELL/PUMP PERMIT <br />