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�//WELL / PUMP PERMIT �/ <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER 7CVE 3""FL-STOCKTON CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED <br /> f�Cam�� g572c� <br /> JOB ADDRESS CITY/ZIP Y <br /> - O <br /> CROSSSTREET APN O�~ II ARCEL SIZE a73LAND USE APPLICATION# <br /> w <br /> OWNER NAME L4 PHONE <br /> OWNERADDRESS CITY/STATE/ZIP C,�Qj(� <br /> CONTRACTOR PHONE <br /> CONTRACTOR ADDRESS CITYISTATE/ZIP A T 1 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP / <br /> LICENSE IB'C-57 ❑C-61 ❑D-09 ❑Other NUMBER EXPIRATION DATE /`f X31 -o L <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range_ Section_ <br /> INTENDED USE ❑Domestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization <br /> ❑Public Water System <br /> Ifdifferentfrom Owns: Wm1 SyMloo N Conaact Nam or Phorc Numb., <br /> TYPE OF WORK ❑New Well ❑Replacement Wellell Alteration edification ❑Test Hole ❑Other <br /> ❑Monitoring Well(s) #of wells [3 Soil Boring(s) N ofbonogs ❑Geotechnical s orborinas <br /> ❑Well Destruction ❑Out-Of--Service Well ❑0 t-Of-Service Well Renewal <br /> ❑New Pum ❑Pum Replacement 13 Pump Repair [D4:ross-Connection Repair <br /> WELL CONSTRUCTION <br /> Drilling Method ❑Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Other <br /> Proposed Well Depth ft Excavation in diameter ❑Open Bottom ❑Gravel Pack/Gravel Sin in diameter <br /> ❑Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter _in Thickness/Gauge/ASTM Sched ❑Steel Cl Plastic ❑Stainless Steel ❑Other <br /> Grout Seal Depth ft ❑Neat Cement(94/h hag/5-10 gal water) ❑Sand Cement .sack mix/7 gal water <br /> ❑Bentonite(20"/solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted N <br /> Grout Placement Method ❑Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑Other <br /> ❑Concrete Pedestal Dimensions: Width ft Length ft Thick in ❑Christy Box ❑Stove.Pipe <br /> PUMP ❑Submersible ❑Turbine ❑Other HP Pump Set R Standing Water Level ft <br /> I 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. 1 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 /> MINI 2 HOUR ADVANCE NOTICE UIRED FOR INSPEcrIONS <br /> SIGNED TITLE DATE ( P <br /> ,7- 1 1.404if <br /> J A U <br /> FF M1 <br /> EN I <br /> DE ARTMENT US ON Y <br /> if� <br /> Application Accepted By Date 7i Area_�(2 Employee ID# <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection By out, <br /> ❑ WAIVER Received <br /> Destruction Inspect n By '/ Date / / Constructed Well Depth it <br /> COMMENTS PA 4' <br /> 94 0 <br /> PE SC Received Chec Amount Date Permit/ Invoice# Well ID# <br /> Codes Info BV ash Remitted Service Re uest# <br /> CJS L 1310 <br /> EHD 4342-(X6 WELL PUMP PERMIT <br /> &NN <br />