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WELUPUMP PERMIT P J I <br /> 'SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 2209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS S f , CITY21P 70001 / <br /> CROSS STREET A N O i� U 2 009 M <br /> PARCEL SIZE LA USE APPLICATION# a <br /> m <br /> m <br /> OWNER NAME G S HoNEE 77 1�'7 -3 <br /> OWNER ADDRESS �' //� CITY/STATE/ZIP Lam✓ / <br /> CONTRACTOR PHONE ^�( _ -//;,)IS <br /> CONTRACTOR ADDRESS S CITY/STATE/ZIP C/� <br /> SUBCONTRACTOR PH E _? /0 LI3 <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> i <br /> LICENSE 57 C 61 D 09 Other NUMBER 6 EXPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y ownship Range Section <br /> INTENDED USE Domestic/Private Irrigation/Agricultural Industrial i Water Quality Mo 'oring Soil Sampling/Characterization <br /> Public Water System <br /> If different from Owner: ater ystem Name ontact Name or one Number <br /> TYPE OF WORK X�lew Well I I Replacement Well I I Well Alteration/Modification !I Other <br /> I Monitoring Well(s) #of wells I 1 Soil Boring(s) #of borings I I Geotechnical #of borings <br /> I I Out-Of-Service Well I Out-Of-Service Well Ren al Cross-Connection Repair <br /> New Pump Pump Replacement Pump Repair I Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Methodyt-_Mud Rotary Air Rotary Auger Cable Tool !Push Point Other <br /> Proposed Well Depth 7j X ft Excavation �_ in diame r Open Bottom Gravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter / Conductor asing Depth ft <br /> Well Casing Diameter- in Thickness/Gauge/ASTM Sched 7 Steel kPlastic 11 Stainle s Steel I Other <br /> Grout Seal Depth_2 ZX) ft I Neat Cement(94 lb bag/ -10 gal water) and Cement sack mix/7 gal water <br /> I_i Bentonite(20%solids) 'I Other <br /> Grout Placement MethoX Pumped I Free Fall 1 I Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By X Driller Pump Contractor/ Other <br /> Concrete Pedestal Dimensions:Width, r ft Length ft Thick in - ! Christy Box Stove Pipe <br /> PUMP �Abmersible Turbine Other ' HP Pump Set ft Standing Water Level ft <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS L CATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS, A ULES AND REGULATIONS. i ALSO CERTIFY THAT PAY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA C ACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MINIMUM,24 HOUR ADVANC I E REQUIRED FOR INSPECTIONS- PLEASE CALL(209A 953--7697 <br /> SIGNED TITLE DATE cy <br /> 1-414 1 14 1 <br /> PAII <br /> N <br /> DEPARTMENT USE ONLY / f <br /> Application Accepted By _ Date a�` Area �/ / < < Employee ID# Ldc", <br /> Grout Inspection By Date _ ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Ins ection By Date Constructed Well Depth ft <br /> COMME 77 7bf <br /> PE SC Receive Amount Permit/Codes Info B Cash Remitted Date Service Request# Invoice# Well ID# <br /> q'34 I W teas q26 g l4 <br /> q3eO �,s�c ►4VJ5'oo-2)' -7 — <br /> �I3� 1 � L/ S 8 (, l <br /> EHD 43-06 �� . WELL/PUMP PERMIT <br /> 4/30/12 <br />