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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3"FL-STOCKTON CA 95202 -(209)468-3420 <br /> 'NON-REFUNDABLE/PEERRM-]ITT /�• C�Ar,�LL 209 95�31f-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS ��(/Vim• �C_'7 f ©1"I(.0 �ll CITY/ZIP -'�C�'//JVt. <br /> CROSS STREET APNO(.�� 6 O•-�� PARCEL SIZE LAND USE APPLICATION"'a #L` � �p <br /> OWNER NAME �[, (Y 1 It�I4.✓' PHONE !//- 2f'� f <br /> OWNERADDRESS LehI CITY/STATE/ZIP S <br /> CONTRACTOR �� •( t'L PHONE 9;-2j—( tif•�I <br /> CONTRACTOR ADDRESS Vl-� CITY/STATE/ZIP 'v <br /> SUBCONTRACTOR PNONE <br /> N <br /> SUBCONTRACTOR ADDRESS CIIT�Y//SSTATF/ZIP <br /> LICENSE Alf-57 ❑C-61 ❑D-09 ❑Other NUMBER&otv 2 Z EXPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section_ <br /> INTENDED USE Domestic/Private ❑Irrigation/Agricultuml ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization <br /> ❑Public Water System <br /> If,lifferent from Owns: Water System Name Conwt Nsine or Phone Number <br /> TYPE OF WORK ew Well ❑Replacement Well ❑Well Altemuon/Modification ❑Other- <br /> 0 Monitoring Well(s) <br /> ther❑MonitoringWeil(s) #of wells ❑SoiIBoring(s) aofnodng ❑Geotechnical xorbonng4 <br /> ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> ❑New Pump ❑Pump Replacement ❑Pump Repair <br /> WELL CONSTRUCTION <br /> Drilling Method XMud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Other <br /> Proposed Well Depth :270 ft Excavation j 2 in diameter ❑Open Bottom Gravel Pack/Gravel Size in diameter <br /> ❑Conductor Casing in diameter / Con r sing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑Steel )MCPlastic ❑Stainless Steel ❑Other <br /> Grout Seal Depth ft ❑Neat Cement(94 1b bag/5-10 gat water) ❑Sand Cement sack mix/7 gal water <br /> tPl!j!entonite(200%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted <br /> Grout Placement Method WP,.pd ❑Free Fall ❑Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑Driller Wmp Contractor ❑ Other <br /> ❑Concrete Pedestal Dimensions:Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe <br /> PUMP ❑Submersible ❑Turbine ❑Other HP Pump Set ft Standing Water Level R <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 I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIED FOR INSPECTIONS <br /> SIGNED ( L �JL-( TITLE V 11! !PN DATE <br /> 77-1 <br /> ( <br /> A DQ <br /> 5 <br /> 1 seri <br /> H / N NT <br /> 2 '2 H M <br /> DE RT ENT SE ONLY T/ <br /> Application Accepted to 13 0 Area Employee ID#i qs'/ <br /> Grout Inspection By 11SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received ee Amount Date / Permit/ Invoice# WeII 1D# <br /> Code Info B ash Remitted Service Request# <br /> tJ Cr o 0 07 fvFih 2C-7t5 <br /> EHD 43-02-006 WELL PUMP PERMIT <br /> 1/272005 <br />