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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 /> C 1 \ G � <br /> JOB ADDRESS —I,J)1 I L y) r`-Q f- 1'<7 n/ CITYMP J I cy,Y i t�i J x I S <br /> CROSS STREET ��I r^�. I) L n APN ZOPARCEL SIZE LAND USE APPLICATION# Uv <br /> OWNER NAME C. 1 cc)i C—k i PHONE V I /1 Cl <br /> OWNER ADDRESS \Sc,M r, CITY/STATE/ZJP C J Cl C.K 1+�1)C&I <br /> l-7 q1- <br /> �. - ,)77q <br /> CONTRACTORy top'(�y �('1„ nh PHONE 30 - tit 7 1 1/ <br /> CONTRACTOR ADDRESS { G 13G l'J CITY/STATE/ZIP (-A 1��CA Ct S <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATEJLP <br /> LICENSE y,C-57 _ C-61 D-09 Other NUMBER, EXPIRATION DATE l/V <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section_ <br /> INTENDED USE XDomestic/Private Irrigation/Agricultural _Industnal Water Quality Monitoring -,Soil Sampling/Characterizaeon <br /> Public Water System AA�� <br /> It diHerenl from Owr: a er ys em arre oname or one um r ^� <br /> 7. <br /> TYPE OF WORK ,New Well - Replacement Well C Well Alteration/Modification ❑Other ieC 4 <br /> Monitoring Wells) #of wells C Soil Boring(s) #of borings Geotechnical #of banngs <br /> - Out-Of-Service Well F Out-Of-Service Well Renewal r'.Cross-Connection Repair /1 r <br /> `/)Jew Pum Pum Replacement C Pum Repair D Raise Well Casing �1 (J ?0�� <br /> WELL CONSTRUCTION - <br /> Drilling Method-Mud Rotary I Air Rotary Auger Cable Tool Push Point Other '� (��� <br /> Proposed Well Depth �' (i ft Excavation 1.� in diameter Open Bottom �Gravel Pack/Gravel Size I!U i O ry C0�/ <br /> Well CasingD g 1 g Depth ft DFp.4R A�� <br /> DiametConder <br /> CasingnThickness/Gaud)e ASTM Sched Conductor Casin De Steel A Plastic Stainless Steel Other MENTI <br /> Grout Seal Depth ft L Neat Cement(94/b bagl5-10 gal water) ,t-Sand Cement1 f I.5 sack mixl7 gal water <br /> Bentonite(20%solids) 'u Other <br /> Grout Placement Method-t7;Pumped c Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By ,t Dnller i_',Pump Contractor Other <br /> ';Concrete Pedestal Dimensions:Width::A_it Length tt Thick _ in -Christy Box -Stove Pipe <br /> PUMP >(.Submersible Turbine Other HP Pump Set 1 C, ft Standing Water Level h <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 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED � Uvy�'4 TITLE DATE <br /> (7 <br /> r 5 <br /> V P T M E N T U N L Y <br /> Application Accepted By ate Area Employee ID# <br /> Grout Inspection By Date PECIAL Well Permit <br /> Pump Inspection By Dale .Z76 IL';: I WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft / <br /> COMMENTS ( •—tl\ V' <br /> PE SC Received Check#/ AmountDate Permit/ Invoice# Well ID# <br /> Codes Info B ash Remitte0 Service Re uest# <br /> 2,0 <br /> EN�.. ,t WELL(PUMP PERMIT <br />