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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONNIErITAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(20914613-3420 <br /> NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FP.ON1 DATE ISSUED <br /> JOB ADDRESS e.e R-,! CITYfZIP III. �^ <br /> D <br /> CROSS STREET Af�)rio f eJ• 4 APN �0 PARCELSIZE LAND USE APPLICATION Yr m <br /> OWNER NAME ltiJ rV�l' / I: n 1,7 _ PHONE 2-019 Lf <br /> OWNER ADDRESS;3 \�E j.2.(/d �G� CITYISTATEIZJP � • v <br /> jag 1,r0At T ZdIG- PHONE Z_Q IC7.- I S (0 7!-7(l) <br /> CONTRACTOR ADDRESS I 0 JG k- )r7�1 P )� CITYISTATE21 <br /> 1P M '/Lk /A <br /> L' I l 9{,,33 In <br /> SUBCONTRACTOR PHONE_ <br /> SUBCONTRACTOR ADDRESS CITY/� /-JISSTATEEJZJPc 7 Z�L�7 <br /> LICENSE C-57 C-61 I D-09 I'.Othef NUMBER-LD D-I 2 l0 EXPIRATION DATE O -�I <br /> DOMESTIC WELL SAMPLING: ;General(Mineral/Coliform Bacteria(4391) 1 Dibromochloropropane(4392) �Arsenic(4393) <br /> INTENDED USE L Domestic/Private 17,I«igafion/Agricultural Induslnal `Nater Quality Morilaring :Sal SamplinglCharactenzauon <br /> ! ! public Wafer System <br /> It d1ff r of tram Owner. Viulel System Nu+:+u Cunla:l Name or Pl+nna Nun,twe <br /> TYPE OF WORK New Well 1 1 Replacement Well :i Well Alleralion/Modificalion I I Other <br /> I Monitoring Wells) z of wells Soil Boring(s) u oI b.ftD Geotechnical ^ <br /> it Out-Of-Service Well Out-Or-Service Well Renewal 1 Cross-Connection Repair A Y41, <br /> New Pum Pum Replacement Pum Re Fair :1 P.aise Well Casing (`�/�/� <br /> WELL CONSTRUC ON ?iec�j� V <br /> Drilling Method L'Mud Rotary A r Rotary I Auger Cable Tool :I Push Point I Other F® <br /> Proposed Well Depth It Excavationin diameter I' Open Bottom I;Gravel PacklCravel Size in damel /�, o <br /> 1 Conductor Casing In diameter Conductor Casing Depth rt !� g �0� <br /> Well Casing Diameter_it ThicknessJGaugelASTM Scned I.Steel Plastic SlaIPIeSS Steel Other <br /> Grout Seal Depth it I"I Neat Cement(94 Ib bag15-10 gal waler) I Sand Cement sack mixn galQUI <br /> II Bentonite(20%sclids) IOther Hr-A ONME ]�- <br /> Grout Placement Method Pumped Free Fall ::Other .I Retardant J Accelerator(name) �EPgRNTAL <br /> PEDESTAL Installed By 1 I Driller Pump Contractor I Other TMENr <br /> Concrete Pedestal: Dimenslons:W In it Length it Thick in I Christy Box 1 Stove Pipe <br /> Punto "Submersible I Turbine : Other HF Pump Set fl Standing Water Level It <br /> 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DOIJE IN ACCORDANCE WITH 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 COMPE9JSATWS. <br /> PdINI M H F(ANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED /C./ TITLE / ���!^ DATE <br /> I <br /> �ZMNT U NLY <br /> Application Accepted 13 e Area Employee fDA <br /> Grout Inspection By 'I + - Date 11 SPECIAL Well Pernniit <br /> Pump Inspection By Dale ?c' !I WAIVER Received <br /> Soil Boring Inspection By - Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Clteck*! Amount PermiU <br /> codes Into 8 ash Remitted Date erviceRe uest# Invoice WeIIID# <br /> E11D<a-06 re�� d 4111,,/16 vVELL'PUtAP PCR.vIIT <br /> Com'�9�z�sg.3 <br />