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WELL/'PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)469.3420 1 <br /> NON-REFUNDA LE PERMIT CALL 2O9 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR o-m DAIE ISSUE <br /> ice ADDRESSL) t on CIN/IIP a/y'�I rv(c4 <br /> D <br /> CROSS STREET AppowAPN —1 "O PARCEL SIZE-0 LAND USE anon# v <br /> m <br /> OWNER NAME � �! r �/1./ V r'PHQ�E W <br /> OWNER ADDRESS IM I A �^ C 3/f /, <br /> CONTRACTOR `� `(J L PHONE /2L10 , d_�+ V ^ <br /> Iy�� tit <br /> CONTRACTOR ADORE 5 V GIN STA l�^ <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR AOORE55 CITY/STATE/21P J ' <br /> I <br /> _ 3l <br /> I <br /> LICENSE C-57C-6t D-09 Other NUMBE� c�c EXPIRATION DATE i 1 <br /> I� <br /> DOMESTIC WELL SAttPUNc: General Mineral/Coliform Bacteria(4391,1 Dibromochloropropane(4392) Arsenic(4393) f I� <br /> INTENDED USE Domestic/Private Irrigation/Agncultdral Industrial Water Quality Monitoring Soil SamplingiCharacterizabor <br /> Public Water System, <br /> it afferent froc 3.er. Nater System Name Contact Name or Pnone Number <br /> TYPE OF WORK Nee;Well Replacement Well Well A!terabon,Mocifcaticn Other <br /> Monitoring'Nellts) 9 o wells Soil B.^rrG:s softwnngs Geotechnical Ad.bwr..ps <br /> Out-Oi-Service Well Out-OT-Sennce Well Renewal Cross-Connection Repair 117 <br /> New Pump amp Replacemen Pump Ret:=;t Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary Air Rotary Auger Caolz 7cr.,, Dash Point Other <br /> Proposed Well Depth ft Excavation .n dmczar Open Bottom Gravel Pack/Gravel Size In diameter) <br /> Conductor Casing in diameter ; Conductor Casing Depth ft <br /> Well Casing Diameter_:n, Thickness/Gauge/ASTM Schecl Steel Plastic Stainless Steel Other <br /> Grout Seal Depth ft Neat Cement(94 lb bagr5--,G gai vrater) Sand Cement sack miz17 gal water <br /> Bentonite(20%solids) Other o <br /> Grout Placement Method Pumped Free Fall Other Retardant!Accelerator(name) ^ <br /> PEDESTAL Installed By Driller Pump COmraCtOr Other <br /> C trete Pedestal Dimensions:Width_ft Len th ft Thick in .Christy Box Stove Pipe <br /> PUMP Vsubmersible Turbine Other HP Pump Set It Standing Water Level It <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> .:OAQUIN COUNTY ORDINANCES, STAT LAWS, AND RULES AND REGULATIONS. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AN ACTIVE WITH THE C RNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WOR OM SATiON LAWS. <br /> W <br /> MI M 24 HOUR A CEN TICE REQUIRED PC )NSPECTIONS-PLEA E CALL(209)95;-7697 W <br /> S!GNEg TRL� <br /> DATE S <br /> I I I <br /> 77-7 <br /> j <br /> I <br /> P4 <br /> Ii j ' i I � <br /> Nj <br /> �NV�o��N C( <br /> l lI l i lh�FpgRT rFHT <br /> l <br /> l <br /> Pip. T M E U/�'7�E//(/N L Y <br /> Aep+tes:lon Accepted By Cale fC ' Area Employee 09 <br /> grout InspeC.lcn By Date E�Well Permit <br /> 'u^;Inspecbon By Data WAIVER Received <br /> Setl Bonne inspection By Data Constructed Weil Depth h <br /> SC Received I hec Amount Permit/ <br /> e info 6 emitter D to Service Re uest# InvoiceWell ID# <br /> JW <br /> WP4_ <br /> --- <br /> i <br /> WELL el'J.AP PERMIT <br />