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{ <br /> WELUPUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1568 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 /> y <br /> JOB ADDRESS L-_2 <br /> 7�:Cj 1.'v,T41 1r�.L ��,�,\eft-•v i CITY21P <br /> CROSS STREE AeA V r APN 2 33 'D2C"C► PARCEL SIZE IO'C9 LAND USE APPLICATION# <br /> OWNER NAME Lot A CA Z fc,LPHONE w <br /> OWNER ADDRESS `zI Zo S \YGC4 Ch: \cVC`r d CITY/STATEMP (IL�j l C�)"t / `t S 1j 7�j <br /> Zy <br /> CONTRACTOR _I \QC �:\`\�(\- PHONE 1 <br /> CONTRACTOR ADDRESS �O X 1�� CRY/STATERIP T'fALy <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CRY/STATE21P <br /> LICENSE D/C-57 ❑C-61 n D-09 ❑Other NUMBER &Q7^-1T0 EXPIRATION DATE <br /> DOMESTIC WELL SAMPLING:❑General Mineral/Coliform Bacteria(4391)❑Dibromochloropropane(4392)❑Arsenic(4393) <br /> INTENDED USE n Domestic/Private n Irrigation/Agricultural n Industrial n Water Quality Monitoring n Soil Sampling/Characterization <br /> n Public Water System <br /> If different from Owner. Water System Name Contact Name or Phone Number <br /> TYPE OF WORK n New Well n Replacement Well n Well Alteration/Modification n Other <br /> n Monitoring Well(s) #of wells Soil Boring(s) -1 #of borings n Geotechnical #of borings <br /> F]Out-Of-Service Well n Out-Of-Service Well Renewal n Cross-Connection Repair <br /> ❑New Pump ❑Pump Replacement n Pump Repair n Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method n Mud Rotary n Air Rotary s/Auger ❑Cable Tool n Push Point n Other <br /> Proposed Well Depth LO' .30 It Excavation in diameter n Open Bottom ❑Gravel Pack/Gravel Size in diameter <br /> n Conductor Casing in diameter / Conductor Casing Depth It <br /> Well Casing Diameter_9L in Thickness/Gauge/ASTM Schad n Steel n Plastic n Stainless Steel n Other <br /> Grout Seal Depth 2-0-3SC ft n Neat Cement(94 lb bag/5-10 gal water) ❑Sand Cement sack mix17 gal water <br /> F1 Bentonite(20%solids) n Other <br /> Grout Placement Method ❑Pumped ❑Free Fall ❑Other I7 Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑Driller n Pump Contractor n Other <br /> R Concrete Pedestal[IDimensions:Width ft Length ft Thick in n Christy Box n Stove Pipe <br /> PUMP n Submersible F]Turbine n 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 /> WORK E S COMPENSATION LAWS. <br /> I UM 4 HOUR AD N NOTIC REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 q <br /> SIGNED TITLE 6Ly'ter DATE <br /> I <br /> � <br /> 0� 209 <br /> 4QU/N C <br /> 0'p ����Y <br /> Application Accepted By P A Mae TT U? Area Employee ID#� T <br /> Grout Inspection By Date IF t ❑ fSPECIALIkell Permit <br /> Pump Inspection By Date F1 WAIVER Received <br /> Soil Boring Inspection By Date Z Constructed Well Depth ft <br /> COMMENTS <br /> PE Sc Received Check#/ Amount Date Permit/ Invoice# Well IDN <br /> odes In BY- Re Service Re uest# <br /> 310 <br /> EHD43-08 reA..,141MI8 WELL/PUMPPERMR <br />