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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> _,q50 N C�,� LQt- 1K <br /> JOB ADDRESS 11 ,t I/ CITYZP J��V,Y i rl t 5 S m <br /> CROSS STREET ri1 I r n I `1 ) APN -Zo PARCEL SIZE�-LAND USE APPLICATION# <br /> //� C m <br /> OWNER NAME �� 1rr1 y �. G PHONE 4V I /1 CI .�^�-7 1 <br /> OWNER ADDRESS \SGMr CITY/STATEI7JP S"r G(,V-6�1)C�-k q., !Jr /L) <br /> CONTRACTOR �I G(it\Y y ��'( 11` X1 /PHONE <br /> 1�'✓�`I - Jl / 7 L/ <br /> CONTRACTOR ADDRESS 1 G �L X CITYISTATE171P l'-/a �"I l P11 Ci,S 1r-:'S <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATEIZIP <br /> LICENSE y.,C-57 _C-61 _.D-09 _ Other NUMBER C `�% EXPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section_ <br /> INTENDED USE XDomestic/Privale Irrigation/Agricultural _ Industnal --Water Quality Monitoring - Soil Sampling/Characterization <br /> Public Water System O <br /> h <br /> If diffnn a ,me o. one om r A <br /> erent om wner: ar Ts em ame #�,•! <br /> TYPE OF WORK New Well -.Replacement Well L Well Alteration/Modification C Other <br /> Monitoring Well(s) #of wells C Soil Boring(s) #of borings Geotechnical #of borings �� <br /> Out-Of-Service Well r-Out-Of-Service Well Renewal n Cross-Connection Repair /r <br /> New Pum C!Pum Replacement C Pum Repair D Raise Well CasingSAN zl 09 ?019 <br /> WELL CONSTRUCTION <br /> Drilling Method )4,Mud Rotary I Air Rotary Auger Cable Tool Push Point Other `� QUA <br /> Proposed Well Depth )r R Excavation 1.7 in diameter Open Bottom A,,Gravel Pack/Gravel Size 11 1 it*i ONIN CIO <br /> Conductor Casing in diameter / Conductor Casing Depth ft OFp'gRTTAC <br /> Well Casing Diameter in Thickness/Gauge/ASTM SchedC�9y;y;_ Steel K Plastic -_Stainless Steel Other MENTI <br /> Grout Seal Depth',i(' it Neat Cement(94 lb bag/5-10 gal Water) )9 Sand Cement )C, S sack mW7 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method?` Pumped Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By (Driller Pump Contractor Other <br /> CConcrete Pedestal Dimensions:Width L4--it Length ft Thick in Christy Box Stove Pipe <br /> PUMP f.Submersible Turbine Other HP Pump Set �=,1- ft Standing Water Level <br /> 1 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 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED /u7��G J<a� TITLE \IC ��'C S Id z v� DATE <J <br /> W <br /> O <br /> I r <br /> I - <br /> tP TMENT U N L Y <br /> Application Accepted By ate Area Employee ID# — <br /> Grout Inspection By VWDate PECIAL Well Permit <br /> Pump Inspection By ''i : ", Date I WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#/ Amount Dat!Info 8 te ash Remitted Service Re uest# Invoice# Well ID# <br /> t _pjC <br /> ETI 47' <br /> 1111/PUMP PERMIT <br /> 6 q�7.3a352 <br />