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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH D&FAUKENT 600 EAST M'.IN S ITEET-STOCKTON CA 95202-(209)SIGH-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-76971'OR INSPI EXPIRES YEAR FROM DATE ISSUED <br /> JouADDRtSS LI w --- Cru Ztr-WNMA —V13 to <br /> CROSS STRELC fleAiA `Q ��{ �J� yr (A�.tP�N,a r -I -- PARCEL SIZE <br /> OWNERNAME � MV)Ti v C \ �l_awf, br 1 \& PHONE <br /> OWNERADDRESS CITY/STATEfLIr , <br /> CONTRACTOR �j7^ //-/jl( ] PlIONE b <br /> IDq <br /> E I—=� <br /> CONTRACTOR ADDRESS�U t 7 � / CRY/STATE/ZIP <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CI1Y/S1.4'1'F/%1P <br /> LICENSE ❑C-57 C 1 ❑Dd19 ❑Other NDMRER Ex►iRATioN DATE <br /> GEOGRAPHICAL INFO IAT10N: Coordinates X Y Township_ Range Section <br /> INTENDED USE uc/Private ❑Inigation/Agricuttural ❑Indma id ❑Water Quality Monitoring [3 Soil Sampling/Charactcruation <br /> ❑Public Water System <br /> If dint 1 firm Owner: Weer Sy, Name Camas Noma a Ph—Number —_— <br /> TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification ❑Test Hole ❑Other <br /> ❑Monitoring WOII(s) nnmberofwma ❑Soil Boring(s) numberoftwriog. ❑Geotechnical - oa beoO d p <br /> ❑Well Destruction ❑Out"_Service well ❑Out-Of--Service Well Renewal <br /> ❑New Pu Replacement ❑Pump Repair ❑CrossLonnection Repair <br /> WELL CONSTRUCTION <br /> Drilling Method ❑Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Other <br /> Proposed Well Depth R Excavation in diameter D Open Bottom ❑Gravel Pack/Gravel Size_ ®t6amder <br /> ❑Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickocss/Gaugc/ASTM Scholl ❑Stcel ❑Plastic ❑Stainless Steel ❑Other <br /> Grout Seal Depth ft ❑Neat Cement(941b bag/5-10 gal muter) ❑Sand Cement suck mix/7 gal water <br /> ❑Bentonite(20%solids) ❑ManufacturerSpec%solids---% Name ❑SpecsonFile ❑Specs Submitted <br /> Grout Placement Method ❑Pimped ❑Free F'ali ❑Other ❑Retardant/Accelerator(name) <br /> PEDES'I:AL Installed By ❑Driilcr ❑Pump COntractar ❑Other <br /> ❑Concrete Pedestal Dimensions: W idlh R Length—ft Thick in ❑Christy Box ❑Stove Pipe <br /> PUMP ubmcrsiblc ❑'rurbine ❑Other HP_-1_ Pump Sd. _ n Standing Water Level ft <br /> WELL DESrRUCTWN ❑Open Bottom ❑Gravel Pack ❑Uncased ❑Other <br /> Well Diameter-_.___in Total Depth R Depth to Water ft ❑Casing to be Perforated from ft to R <br /> Scaling Material ❑Neat Cement(94 1b bag/5-10 gal%vter) ❑Sand Cement _sack mix/7 gal water ❑Bentonite Pellets <br /> ❑Bentonite(20%solids) ❑Manufacturer Spec%solids_a/ Name ❑Specs on File ❑Specs Submined <br /> Placement Method ❑Pumped ❑Free Fall ❑Other -_ <br /> ❑Complete with Mushroom Cap ft below grade ❑Completc to Existing Surface Pad <br /> 1 HEREBY CERTIFY THAT 1 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 AN E ACTIVTit RNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH Aid. <br /> woRKE <br /> A V.ANCE NOTICE RREEQ/`11/yL/�/I R INSPECTIONS <br /> --- --- Tit � <br /> Le 1LW—/L'-b�-�-- <br /> '41 Acly/ <br /> PAYMENT <br /> ECEIVED <br /> AY 0 2 2019 <br /> JOAQUIN COUNTY <br /> _ VIRONMENTAL <br /> TH DEPARTMENT <br /> .PARTMENT LY <br /> Application Accepted By i Dale _ Afea _ ._._ mployee IDN __ __ <br /> ov <br /> Grout Inspection By Date SPECIAL We11 Permit <br /> Pump Inspection Byax�tam Date ❑ WAIVER Received <br /> Destruction Inspection By Daft_ Constructed Nell Depth It <br /> COMMENTS -------- _- <br /> PE SC Received Amount Date Permit/ Invoice" W'e111Dif <br /> C es Info Cash Remlfed Service R Rest R <br /> Lb <br /> EHD 43-02-006 WEB Well Permi7 and Des lavation doe <br /> 9/11/2007 <br />