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•r <br /> WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1068 EAST HAZELTON AVENUE-STOCKTON CA 95206-6232(209)469-3420 <br /> NON-REFUNDABLE PER r WWW,Sjgoy.org/ehd _EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS � oq CITYIZIP R - _-_ 95y�bb y <br /> CROSSSTREET Mwrbm �i_ APN-'ZO'3.2.7Z b3 PARCELSIZE 11_41 LAND US_EQAPPPPLILICATION# D <br /> OWNER NAME Thj[�/��eyda 1 PHONE 9 bZ— ()Z48 N <br /> n /y <br /> OWNER ADDRESS Loot E F I S it-, Z �� CITYISTATE/ZIP &Rw-I Cr `�,S3" <br /> CONTRACTOR Mau11 ll�n -like. —'-- h w <br /> -----. A� PH�ONE_t I� /�� �x/2 n <br /> CONTRACTOR ADDRESS Ibcrs CITYISTATE/ZIP1HcG�tSfb -I r3S'7 <br /> SUBCONTRACTOR/CONSULTANT PHONE <br /> SUBCONTRACTOR/CONSULTANT ADDRESS CITYISTATE/ZIP <br /> LICENSE XC-57 D C-61 r_I D-09 11 Other— NUMBER41&0221— EXPIRATION DATE?/nZ <br /> BILLING PARTYI OWNER CONTRACTOR SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING:!,General Mineral/Coliform Bacteria(4391)!,Dibromocllloropropane(4392)-i Arsenic(4393) <br /> INTENDED USEDomestic(Privale D Irrigation/Agricultural O Industrial -D Water Quality Monlloring Ll SOI(Sarnpling/Characterfzallon <br /> D Public Water System <br /> I(dlfferenl from Owner: Water Systema Conled Name or Phnne Number <br /> TYPE OF WORK )(New Well D Replacement Well D Well Alleral(on/Modificallon U Other <br /> — <br /> U Monitoring Well(s) If of wells IJ Soil Boring(s) x of borings 0 Geotechnical a of borings <br /> I]Oul-Of-Service Well 0 Out-Of-Service Well Renewal D Cross-Conneclion Repair <br /> _ 0 New Pump C1 Pump Replacement O Pump Repair D Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary n Air Rotary n Auger EI Cable Tool U Push Point Cl Other <br /> Proposed Well Depth '710_ry Excavation 1.2 _in diameter CI Open Bottom `q Gravel Pack/Gravel Size__in diameter <br /> U Conductor Casing In diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_6 in Thickness/Gauge/ASPM Sched "2 QV U Steel XPlasl(c n Stainless Steel U Other <br /> Grout Seal Depth 1Qy ft U Neat Cement(94 lb bag/5-10 gal water) D Sand Cement__ sack mix/7 gal water <br /> J<Bentonite(20%solids) 0 Other <br /> Grout Placement Method`K Pumped U Free Fall O Other n Retardant/Accelerator(name) <br /> �—PEDESTAL Installed By n Driller U Pump Contractor 0 Other <br /> 0 Concrete Pedestal ODtmenslons:Width ft Length It Thick in O Christy Box 0 Stove Pipe <br /> f PUMP 0 Submer_slbler_I Turbine O Other _ HP_— Pump Set_ ft Blending Water Level fl <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 /> MINI 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED_ TITLE 64C.-p—, <br /> -- DATE <br /> r <br /> A — <br /> _ 1 <br /> UI <br /> ff Tff7 <br /> E1 SIWAO1Z- R T M E N TU E O LY <br /> Application Accepted By _ Date-- Area Employee ID# <br /> Grout Inspection By_ Date I SPEC AL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Inspection By_ — Date Constructed Well Depth ft <br /> COMMENTS ` <br /> PF Sc Received Check#/ Amount Permit/ <br /> Cods <br /> Into Cash j emitted ate Service Request# Invoice# Well ID# <br /> EHp an-fxt roil/"1n IP <br /> 7 WELL(PUMP PERMIT <br /> �V <br />