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I WELUPUMP PERMOT <br /> J <br /> S`N OAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 55205 - (209)468-3420 <br /> -NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR 6NSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS _. �/ /VL-J 1,-E _ CITY/ZIP � 10P-----q-�J n <br /> 'CROSS STREET L-��� � APN i D _ ARCEL SIZE LAND USE APPLICATION#_ <br /> m <br /> .S <br /> OWNER NAME (,11jL''A�(� .^ l✓ - - - 'PHONE" � .� 'f C `� ryn <br /> OWNER ADDRESS 7J L//7 J CITY/STATE/ZIP 6Z T <br /> CONTRACTOR JCS C7/Z�S� 1'/���^ IPI PHONE 3 `Y- ` -7 0- <br /> D n I ^1 -- <br /> CONTRACTon ADDRESS -r D ✓ [ 7� __- CITY/STATE/ZIP CrX� IZ� <br /> SUBCONTRACTOR _0���' � <br /> PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP- <br /> 7 7� <br /> LICENSE C-57 C-61 D-09 Other_ NUMBER-.> 7-)`J amEXPIRATION DATE�y <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range_ Section <br /> INTENDED USE a Domestic/Private Irrigation/Agricultural Ll Industrial ❑ Water Quality Monitoring Soil Sampling/Characterization <br /> Public Water System_ <br /> If different from Owner: Water ystem Name _ Contact Name or Phone umber <br /> TYPE OF WORK New Well Replacement Well ❑ Well Alteration/Modification Other J*®A�., <br /> n <br /> 7 Monitoring Wells) #of wells ; Soil Boring(s) N of borings Geotechnic gs <br /> .i Out-Of-Service Well 11 Out-Of-Service Well Renewal iJ Cross-Connection Repair ���� <br /> hew Pum Pum Replacement !1 Pum Repair 0 Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method>Mud Rotary ] Air Rotary Auger Cable Tool Push Point r1 Other JO 1 <br /> Proposed Well Depth S aO ft Excavation �_ in diameter Open Bottom 'ZGravel P / r �O_UNT�, In diameter <br /> Conductor Casing in diameter / Conductor Casing Depth _ _ft �pARr <br /> Well Casing Diameter j?- in Thickness/Gauge/ASTM Sched .,?L IJ Steel }Mastic Stainless Steel Other <br /> Grout Seal Depth c 0 ft Neat Cement(94 Ib bag/5-f0 gal water) >Sand cement�J sack miu/7 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Methods Pumped Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By XDriller Pump Contractor� Other <br /> Concrete Pedestal Dimensions:Width / ft Length ft Thick in Christy Box Stove Pipe <br /> PUMP Submersible Turbine Other HP 'LjL 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 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 COMPENSATION LAWS. <br /> MINIMUM 24 HO R ADVANCE NOTICE REQUIRED FOR INSPECTIONS- PLEASE CALL (209)/953-7697 <br /> SIGNED �'�-^ TITLE ")LAJ,`%- _ - DATE e✓T <br /> _ / %; <br /> C <br /> r <br /> D PA TMENT USE qNLY <br /> Appiication Accepted By Date - �� _ Arc � `�-- r: C) iC:„ <br /> Grout Inspection By 1A Date 4 ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE Sc Receivedhe Amount Permit/Codes Info B as Remitted Date Service Request# Invoice# Well ID# <br /> EHD 43-06 WELL/PUMP PERMIT <br /> 4/30/12 <br />