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WELL/PUMP PERMIT <br /> SAN JOAOUIN COUt1TY ENVIRONNIEtITAL HEALTII DEPARTIAENT 1068 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232(209)468-3420 <br /> NON-REFUNDABLE PERMIT www.sjgov.org/ehcl _ EXPIRES 1 YEAR FROM^D�ATEISSUED <br /> Joe ADDREss1-4 Clry/Z1P� /a,, 19-3-31D <br /> No�*IAMd 2 V-opo-030 PARCEL SRE l <br /> CROSS STREET APN LANG US/E/APPLICATION# v <br /> OWNER NAME �'�'j�J���1(� �11 Q-,/�1'Q- ,{/(� PHONE}(i.U�9.gl/]5G• lDgIDS� <br /> OWNER ADDRESS J%AIV �IUjNK/'(/���'{[//� 1�� CITYISTATEIZ1Py �'I /� <br /> CONTRACTOR � S"�JIII QS DI IVQ(A f�I/ PUONEM!j 5, L• 112 O <br /> CONTRACTOR ADDRESS Ilq 111 rJ t CITYISTATEIZIPf <br /> SUBCONTRACTORICONSULTANT_ PHONE <br /> SUBCONTRACCTO�RICONSULTANT ADDRESS _ C`YJSTATE)ZIP <br /> LICENSE ,X(:-57 1BV <br /> .1 C-61 (,D-09 II Other NUM <br /> ER�2-2— EXPIRATION DATE 3U O <br /> BILLING PARTY: IOWNER CONTRACTOR SUBCONTRACTOR/CONSULTANT <br /> DoMEST1C WELL SAMPLING: General MinerallColiform Bacteria(4391) Dibromochloropropane(4392)• Arsenic(4393) <br /> FLINTENOED USE DDmeslldPrivale q Irdgallon/Agdcullural I Industrial Water Quality Monitoring U Soil Sampling/Cheracteriza lion <br /> D Public Waler System <br /> II,11ft and Iran,O"ec Water SyeA1n Name C-I.d Narna or Phmlo Numba, ^� A- <br /> TYPE OF flew Well LI Replacement Well 'I Well Mleratlon/Modification D Other �•!^ � <br /> P Menllorin Wells #DI Wells V Soil BDdO •olboonea Norbnhlea A��•I <br /> g O g(s1 U Geotechnical <br /> rr <br /> U Oul-ofServlce Well 0 Out-Of-Service Well Renewal LI Cross-Connectlon Repair �D <br /> _ n New Pump D Pump Replacement 17 Pump Repair 0 Raise Well Casing AR <br /> WELL CONSTRUCTION ^ <br /> Drilling Mothod)(Mud Rola I)Alr Rolary U Auger U Cable Tool U Push Point D Other 3 ^O�O <br /> ProposedWell Depth n acavalion in diameter ❑Open Bollom G Gravel ParklGravel Size In dia� A ` <br /> 0 Conductor Casing In diameter I Conductor Casing Depth p /R NM (,`p <br /> t Wall Casing Dianieler ALin ThicknesslGauge/ASTM S(:Iled U— 0 Steel Plastic U Stainless'feel 1 i Other HEAL DEPAR 7.AL <br /> Grout Seal ���Depth�_ft II Neat Cement(941h bag/:rlOgal Wafer) r Sand Cement sack mix/7 gal vyaler ARTMENT <br /> �enlonife(20%solids) LI Other <br /> Grout Placement Method XPumped 1..1 Free Fall L?Other _ U Retardant I Accelerator(name) <br /> PEDESTAL Installed By I:1 Driller (I Pump ConlraclRr - D Other <br /> U Concrete Podeslal ODlmenslons:Width n Length (I Thick In D Christy Box U Stovo Plpo <br /> IPUM— <br /> P U Submersible(t Turbine r.Other I IP Pump Sel it Standing Water Level_ Il <br /> I HEREBY CERTIFY THAT I HAVE PREPAREQ THIS.APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> s JOAQUIN COUNTY ORDINANCES, STATE' 6: ANb,RUL�S 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 /> ADVANCE NOTICE REQUIRED F P TIONS-PLEASE CALL(2091963-7697 <br /> SIGNED <br /> I <br /> 7i <br /> ' r <br /> Application Accepted 6y - Dore- Wee �• Emptoyee'Ib* •h� <br /> t Grout Inspection By Dale .I '- P CIAL Well Permit <br /> Pump Inspection By Dale_ WAIVER Received <br /> Soil Doring In^sTp cl n BY - Date Constructed WDII Dep h It <br /> CONIME TS f/�( ('t— (� L6 <br /> PE 9C Recelved Clock#r Amount Ponnitl <br /> ICodes InfoB rill Roml'llto��d� Date $prvlco Re uost# Invoice# --Well ID# <br /> t E'1130 la 511,0019 11KZLL(PUMP PERMIT <br />