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WELL / PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WeeeRe 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 /> JOB ADDRESS <br /> / �NV/ /�1Vl a CITY/ZIP &//l <br /> _ a offl <br /> /f /� (f'L+�� C <br /> CROSS STREET APN 1,/�03-jQ E/' 7 PARCEL SIZE 7rAND USE APPLICATION# <br /> N <br /> OWNER NAME /PHONE <br /> f <br /> OWNER ADDRESS �f <br /> CITY/STATE/ZIP JI�1 �� <br /> ,2 ?—CCONTRACTOR - PHONE 7,27--- <br /> CONTRACTOR <br /> ONTRACTOR ADDRESS1/2 <br /> CITY/STATE/ZIP <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> PIRATION DATE <br /> LICENSE 7 0 C-61 0 D-09 0 Other NUMBER EX <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township _ Range Section_ <br /> INTENDED USE 0 Domestic/Private 0 Irrigation/Agricultural 0 Industrial 0 Water Quality Monitoring 0 Soil Sampling/Characterization <br /> 0 Public Water Systemt <br /> If different from Owner: Water ystem am .onmet Name or one um er _ <br /> TYPE OF WORK 0 New Well ❑Replacement Well ell Alteration/Modification 0 Test Hale 0 Other <br /> ❑Monitoring Well(s) #of wells ❑Soil Borings) aofbmings ❑Geotechnical #ofbmmp <br /> 0 Well Destruction 0Out-Of--Service Well 0Out-Of-Service Well Renewal <br /> 0 New Pump 0 Pump Replacement 0 Pump Repair01ross-Connection Re air <br /> WELL CONSTRUCTION <br /> Drilling Method 0 Mud Rotary 0 Air Rotary 0 Auger 0 Cable Tool 0 Push Point 0 Other <br /> Proposed Well Depth It Excavation in diameter 0 Open Bottom 0 Gravel Pack/Gravel Size in diameter <br /> 0 Conductor Casing in diameter / Conductor Casing Depth it <br /> Well Casing Diameter _in Thickness/Gauge/ASTM Sched ❑Steel ❑Plastic ❑Stainless Steel ❑Other <br /> Grout Seal Depth ft 0 Neat Cement(94 Ib hag/3-10 gal water) 0 Sand Cement .cock mix/7 gal water <br /> 0 Bentonite(20%solids) ❑Manufacturer Spec%solids_% Name ❑Specs on File 0 Specs Submitted <br /> Grout Placement Method 0 Pumped 0 Free Fall 0 Other 0 Retardant/Accelerator(name) <br /> PEDESTAL Installed By 0 Driller 0 Pump Contractor 0 Other <br /> ❑Concrete Pedestal Dimensions: Width ft Length_ft Thick in ❑Christy Box 0 Stove Pipe <br /> PUMP 0 Submersible 0 Turbine 0 Other HP Pump Se[ ft Standing Water Level ft <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. 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 /> MIN M HOUR ADVANCE NOTICE RUED FOR INSPECTIONS <br /> SIGNED r TITLE �� ! - DATE ' <br /> 1 <br /> N <br /> O NT <br /> E p T <br /> EPARTMENT <br /> Application Accepted By Date Area 2/ 2 Employee ID# <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection By Date //p J ❑ WAIVER Received <br /> Destruction Inspection By (� Date _ <br /> Constructed Well Depth ft <br /> COMMENTSQ R Q .�—Q <br /> PE SC Received Chu Amount Date Permit/ Invoice# WeII ID# <br /> Codes Info B Cash Remitted Service Re out# <br /> 3 � � <br /> WELL PUMP PERMIT <br /> END 40-02-Wfi <br /> Nd04 <br />