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KEYED <br /> WELUPUMP PERMIT <br /> SAN JOAQUIN COUNTY ENviRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELToN AVENUE-STOCKTON CA 96206-6232(209)4683420 <br /> NON-REFUNDABLE PERMIT z2a <br /> EXPIRES 1 YEAR FROM DATE ISSUED <br /> CITv/ZlJOB ADDRESSCROSSSTREETon <br /> APN �• EL SIZE LAND USE AAPLPLQICA(TION#4 <br /> 27.7 -Z• PHONE <br /> OWNER NAME 2 `l ) <br /> OWNER ADDRESS n U� v 7- r C[TYISTATFILP- <br /> J �,tS- IN <br /> CONTRACTOR C, - PHONE�1{ (' 91.5 <br /> /-'(y �A{,t,�) <br /> CONTRACTOR ADDRESS S� I CITYlSTATFJAP�t a6iX 1 1 `14 `51` 0 <br /> SUBCONTRACTORICONSULTANT PHONE T <br /> SUBCONTRACTORICONSULTANT ADDRESS GYTYISTATEILP <br /> a <br /> LICENSE %/-57 C-61 - D-09 �1 Other NUMBER 4 SA IlEXPIRATION DATE <br /> BILLING PARTY: :OWNER ('CONTRACTOR -SUSCONTRACTORICONSULTANT <br /> DOMESTIC WELL SAMPLING: General MineraVColifonn Bacteria(4391) Dibromochloropropane(4392)-i Arsenic(4393) <br /> INTENDED UsE -DomestcrPrivaie r: IrrigalionlAgricuitural -industrial Water Quality Monitoring Sad Sampling/Characterization <br /> ;;;] <br /> Public Water System <br /> If oiRerem ftom Owner: Water System Nemo Contad 1Jame m Phone Numbet <br /> TYPE OF WORK New Well - Replacement Well !"'Well Alteration/Modification _'Other <br /> Monitoring Weil(s) #of wells -Soil Borings) Sorbonngs Geotechnical aot b0'Nbs <br /> Out-Of-Service Well "Out-Of-Service Well Renewal -.Cross-Connection Repair <br /> New P ..:Pump Replacement Pump Repair Raise We11 Cas <br /> in <br /> WELL CONSTRUCTIO <br /> Drilling Method _Mud Rotary L;Air Rotary L Auger i.Cable Tool Push Point Other <br /> Proposed Well Depth ft Excavation in diameter Open Bottom l Gravel Pack/Gravel Size in diameter ' <br /> _ Conductor Casing in diameter I Conductor Casing Depth ft <br /> WellCasing Diameter_in ThlcRnesslGaugefASTM Sched Steel Plastic Stainless Steel 'i Other <br /> Grout Seal Deplh R Neat Cement(94 Ib Dagl5-1`0 gal wafer) Sand Cement sack mixt?gal water <br /> Bentonite(20`k solids) Other pw <br /> Grout Placement Method ,Pumped -,Free Fall "Other .Retardant/Accelerator(name) wA/y Ie�•-J <br /> PEDESTALInstalled By - OriUer i.;Pump Contractor ; Other RFc��Nr <br /> ''Concrete PedestaU:Dimensions:Width_ft Length ftThick in =Christy Box Stove Pipe VF <br /> LU—MP Submersrhle Turbine Other HP o Set [7 R Standing Water 1—1 D <br /> i HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN A(.C.VKIJ/>trt-C rwrn (/v O�j <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS,AND RULES AND REGULATIONS. 1 ALSO CERTIFY THAT MY REQUIRED LICENS�',Q$r O �/ ?019 <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH A qQU/N <br /> WORKERS COMPENSATION LAWS. <br /> tall SUM C u(^I R.ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE <br /> CALL(2 $3-5 7 C CSL oFpM�DATE NT IV <br /> SIGNED � <br /> MFNT <br /> _ e Wil <br /> PA T[/ MEr N T U E O LY <br /> Application Accepted By�j!! .�5 /�` D e Area _ Employee ID# <br /> rT� � v'T <br /> Grout Inspection By -Imo/--� Date 1 SPECIAL Well Permit <br /> Pump Inspection By t7flxi . Date 1 WAIVER Received <br /> Soil Boling Inspection By / Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Chack#1 Amount Date PermN Invoice# Well IDB <br /> Codes I Info ash Remitted S rvi Reqqig# <br /> 9 WELLIPUMPPERMR <br /> LC41346111r201976 6rtit9 �� ! ���/!3 <br />