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1 <br /> WELVPUMP 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 /> c A4 � to <br /> JOB ADDRESS I CfrY2iP ma <br /> � i�( v <br /> CROSS STREET / /y�, {r�APN �.+5u I lQO 0,. PARCEL SIZa�LAND USE APPLICC IONR# <br /> OWNER NAME �i I Vl C� /�1„ 1�r�f1, PHONE 2&Y <br /> OWNER ADDRESS .7�L rn� CITY/STATE/Zip ('� <br /> CONTRACTOR V- � Vr ,, PHONE-0-Vi. <br /> '/`vl O <br /> CONTRACTOR ADDRESS C �'�/! �'�'�'"(W CITY/STATE/ZIP P,1 60-V)L/C4q <br /> SUBCONTRACTOR r1` yam./ PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATEtZIP <br /> Z U <br /> LICENSE C-57 L C-61 U D-09 U Other NUMBER I PEXPIRATION DATE ` <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section_ <br /> INTENDED USE Domestic/Private 7 Irrigation/Agricultural ❑Industrial 7 Water Quality Monitoring C Soil Sampling/Characterization <br /> U Public Water System <br /> • If blit nt fromate Ownec Water 6YSteM NaMB Contac ame or Phone Number A q' <br /> TYPE OF WORK New Well L Replacement Well U Well Alteration/Modification U Other <br /> #of borings #ofborings <br /> ❑Monitoring Well(s) #of wells ❑Soil Boring(s) ❑Geotechnical <br /> O Out-Of-Service Well ❑Out-Of-Service Well Renewal 0 Cross-Connection Repair <br /> U New Pump L Pump Replacement U Pump Repair U Raise Well Casing <br /> WELL CONSTRUCTION %J 4 ?019 <br /> Drilling Method Rotary C Air Rotary C Auger ❑Cable Tool ❑Push Point ❑ Other '�Y Qui I <br /> Proposed Well Depth 30 O ft Excavation�_in diameter U Open Bottom U Gravel Pack/Gravel Size in O/v H Cp T,- <br /> n Conduc or Casing in diameter / Conductor Casing Depth It F M��r��'7 <br /> Well Casing Di ter in Thickness/Gauge/ASTM Schad rt Steel Plastic n Stainless Steel �Other �RT�F <br /> Grout Seal D pt�il ft C Neat Cement(94 lb bag/5-10 gal water) ❑Sand Cement sack m&7 gal water <br /> NT <br /> ,Bent nite(20%solids) L Other <br /> Grout Placement Method Pumped D Free Fall C Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By 7 Driller V Pump Contractor 7 Other <br /> ❑Concrete Pedestal ODInfenslons.Width ft Length ft Thick in ❑Christy Box O Stove Pipe <br /> PUMP ❑Submersible?Turbine C Other HP Pump Set it 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. 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 ATION LAWS. <br /> MI IMU O ADV NCE NOTICE REQUIRED FOR INS lTCTTIONNS-PLEASE CALL(209)953-769 <br /> SIGNED TITLE DylI `--� DATE <br /> A MENT UJFE O L <br /> Application Accepted By Date Area Employee ID#_16�� <br /> Grout Inspection By :� Data ❑ PECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Recelve _ <br /> Soil Boring Inspection By Date Constructed Well Depth v ft <br /> CO ENTS - �72 <br /> war <br /> Lffi <br /> PE SC Received O Amount Permit/ <br /> Codes Info B s Remitted Date Service uest# Invoice# Well h /�A (r <br /> 7/157 /9 <br /> 91 VEWY1710 <br /> EHD 43-05 WELL/PUMP PERMIT <br /> 4130/12 <br />