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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 310 FL-STOCKTON CA 95202-(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR I%SPLCTIONS EXPIRES I YEAR FROMDATEISSUED <br /> p�o�/� a <br /> JOB ADDRESS CITYfZIP 6 <br /> .{� 1 O <br /> µ—A��C� APN 0S O C� PARCEL SIZE r VL AND USE APPLICATIONM <br /> CROSS STREET / <br /> OWNER NAME L9�IAr�i�17w5 PHnONE� <br /> OWNER ADDRESS Crry/STATE/ZIP <br /> CONTRACTOR !Y/LC/�///��%!tC" f1�l'�+�j� PHONE <br /> CrTYISTATEJZIP •G!'�'7" �� !-7 L�� <br /> CONTRACTOR ADDRESS <br /> SUBCONTRACTORPHONE <br /> .r � /j "�CL <br /> SUBCONTRACTOR ADDRESS//L�/ N�'zq �C-- CITY/STAATFIZIP <br /> LICENSE -57 -61 ❑D-09 ❑Other NUMBER 00/ EXPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Rangt Section_ <br /> INTENDED USE mestic/Privatc ❑Irrigetion/Agricultunl ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Chancteriation <br /> ❑Public Water.S onnct —or u r <br /> tfd,rt tfran t — y— .me <br /> TYPE OF WORKIV4cw Well ❑Replacement Well ❑Well Alteration/Modification ofb❑o Other sofborinp <br /> [3 Monitoring Well($) s <br /> #of wells ❑Soil Boring(s) ❑Geotechnical <br /> ❑Out-0f-Service Well ❑Out-0f-Service Well Renewal ❑Cross-Connection Repair <br /> N;New Pump ❑Pump Replacement ❑Pump Repair <br /> WTI.L CoNiraN <br /> Drilling Method ud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Other <br /> Proposed W�h 2z ft Excavation__ in diameter ❑Open Bottom ravel Pack/Gavel Size in diameter <br /> ❑Cond for Casing in diameter / Conductor Cuing Depth / ft <br /> Well Casing Diamde ,^nn ThicknesslGaugdASTM Schad _L.an ❑Steel�astic ❑Stainless Steel ❑Other <br /> Grout Seal Depth ft ❑Neal Cement(94 lb bag/S-/0 gal w ler) ❑Sand Cemen[ sack mir/7 gal water <br /> entonite(20G solids) ❑Manufacturer Spec%solids_% Name ❑Specs on File ❑Specs IS? <br /> Grout Placement Method meed ❑Free Fall ❑Other ❑Retardant/Acceleator(name) <br /> PEDESTAL installed By ❑Driller mp Contractor ❑ Other <br /> ❑Concrete Pedestal Dimensions:Width R length ft Thick in O Christy Box ❑Stove Pipe <br /> PuNtrNAubmersibic ❑Turbine 13 Other HPZ Pump Set ft Standing Water Level ft <br /> 1 HEREBY CERTIFY THAT 1 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. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> /IMUM 24 HOUR ADVANCE NOTICE RE(�U-IREDDFFO�R II/NSSPPECTIONS <br /> SIGNED /I ' // i` ( � TrTLE `/'�CL ,Pr_ DATE <br /> X <br /> x <br /> _ µ <br /> D P RTMENT US O LY <br /> Application Accepted By Date l O Area Employee ID#�l�r <br /> Grout Inspection B Date !(J ❑ SPECIAL Well Permit <br /> pump Irupection By Date ❑ WAIVER Received <br /> Constructed Wpmpth ft <br /> COMMENTS yl� Zl✓�l7ia /f7 L(2� SFS <br /> PE SC Received Amount Date Permit/ Invoice# Well 1D# <br /> Codes I Info By Cash RemittedService R uest# <br /> Ul PA 0'-"(G <br /> DO _.9' <br /> WELL PUMP PERMIT <br /> END 4342006 <br /> 117!1005 <br />