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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 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 /> m <br /> _L to <br /> JOB ADDRESS 1 tl(J I- �(��l rl V- �� 1/ CITY21P Ae C4 LN1 Q rZ ,-/ 2 l J <br /> 1 ff 1 v <br /> CROSS STREET _L o l o T y APN 0 Vf I f�J�� -PARCEL SIZE LAND USE APPLICATION# m <br /> OWNER NAME . Icy, �Y� I Z JDS '� 2ab to - /�`�- !�l'`� .—._PFi/lit , �S2-� <br /> OWNER ADDRESS // -7 )�ij n I)1-OO 11 1• I j /�7 w I rn C-ITY/STATE/ZIP <br /> CONTRACTOR PHONE <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP_ <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE , `: C-57 I C-61 I D-09 I1 Other NUMBER_ EXPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDS' USE f.1 Domestic/Private Y Irrigation/Agricultural C1 Industrial i Water Quality Monitoring EJ Soil Sampling/Characterization <br /> I I Public Water System <br /> If different from Owner: Water System Name fact ame or Phone umber <br /> TYPE OF WORK n New Well I1 Replacement Well ❑ Well Alteration/Modification CI Other <br /> ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) _ #of borings _ Geotechnical #of borings <br /> `, Out-Of-Service Well U Out-Of-Service Well Renewal U Cross-Connection Repair <br /> _ I' New Pump Pump Replacement ❑ Pump Repair C1 Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method a Mud Rotary Il Air Rotary I1 Auger Ll Cable Tool L1 Push Point ❑ Other <br /> Proposed Well Depth ft Excavation in diameter -1 Open Bottom 1_1 Gravel Pack/Gravel Size in diameter <br /> ❑ Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched '_1 Steel Ll Plastic C Stainless Steel -I Other_ <br /> Grout Seal Depth . It ,1 Neat Cement(94 Ib bag/5-10 gal water) 2 Sand Cement sack mixd7 gal water <br /> I Bentonite(20%solids) `1 Other <br /> Grout Placement Method I Pumped Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By -1 Driller Pump Contractor _ Other <br /> Concrete Pedestal Dimensions:Width ft Length ft Thick in F- Christy Box F-' Stove Pipe <br /> lr'uMP Subrnersibie i urbine 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 Wi T H 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 /> WORKERS COMPENSATION LAWS. <br /> MINIMUM 24 OOUR ADVANCE NOTICE REQUIRED FQR INSPECTIONS - PLEASE CALL(209)953-7697 <br /> SIGNED TITLE C �S t n­ll ( /J l`Q V DATE 10-22-/7 <br /> -JIf 11('. <br /> y <br /> S N y <br /> V1,;':O ' O <br /> � <br /> / ///. �j UtPAR T MEN T USE UNL Y !� <br /> Application Accepted By / liU4 � /L�Z Date Area _/ Employee ID# LOCI <br /> Grout Inspection By Date 0 SPECIAL Well Permit <br /> Pump Inspection By Date 0 WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS U��_ tL ct A L'✓P oj,) c ( cI Ilt I r , .13 <br /> edy <br /> "Ne-, 14 V Z F-7 <br /> PE SC Received Check#/ Amount Permit/ <br /> Codes Info By ash Remitted Date Service Request# Invoice# Well ID# <br /> EHL 43-06 WELL/PUMP PERMIT <br /> 4/30/12 <br />