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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 85205-(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEARFROMDATE ISSUED <br /> Q <br /> JOB ADDRESS `-'-7 " �t f-0 t{`.fe Y,I CITY/LP C)(I <br /> CROSS STREET L 1 hPet' Il D AP�N-+ p �`�+ �! PARCEL SIZE /- LAND USE APPLICATIONS / m <br /> OWNER NAME fV,' D c' \ �; 'vim' ` E� PHONE �Cl l� 110 3�W <br /> OWNER ADDRESS S`1 CITY/STATE/LP Z <br /> CONTRACTOR \ P-0 <br /> PHONE J V CI �7/7Cq <br /> CONTRACTOR ADDRESSS-l/� 6 o Y( CrTY/STATE/Z1P C(A 1 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/AP <br /> LICENSE 5 C-57 _ C-61 D-09 Other NuMeER X I J5 ExwRAnoN DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section <br /> INTENDED USE DomesSc/Pnvate Irrigation/Agricultural Industrial Water Quality Monitoring Soil Sampling/Characterization <br /> Public Water System <br /> If tliff—M from Owrxr. W~SystemN­ <br /> TYPE, <br /> a ame or um <br /> TYPE OF WORK New Well Replacement Well C Well Alteration/Modification Other <br /> Monitoring Well(s) #of wells C Soil Bonng(s) 't of bonngs Geotechnical n of borings <br /> Out-Of-Service Well _ Out-Of-Service Well Renewal Cross-Connection Repair <br /> ;..New Pum _ Pump Replacement Pump Repair _ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method.'Mud Rotary Air Rotary Auger Cable Tool Push Point Other <br /> Proposed Well Depth -2,4�J ft Excavation in diameter - Open Bottom r Gravel PadUGravel Size n diameter <br /> Conductor Casing in diameter ! Conductor Casing Depth ft <br /> Well Casing Diameter�in Thickness/Gauge/ASTM SchedC i;j _ Steel ,(Plastic Stainless Steel Other <br /> Grout Seal Depth i('.(-' ft Neat Cement(94/b bag/5-10 gal water) Sand Cement sack mixl7 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 /> Concrete Pedestal Dimensions:Width It Length It Thick in Christy Box Stove Pipe <br /> PUMP Submersible Turbine Other HP ca Pump Set It Standing Water Level +..(.(, It <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 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS, <br /> MINIMUM 24/JIJOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED / /LLQ^u"' TITLE \J .0 L I C GIS I'1- DATE i ��- <br /> C I ry_ <br /> 1 -471 <br /> J <br /> L. `� EI11T <br /> Via <br /> 2020 <br /> N <br /> OuNTy <br /> TAS <br /> MENT <br /> E RTMENT USE ONLY <br /> Application Accepted B Date 2, Area ( Employee ID#-_ <br /> Grout Inspection By Date U:500(1020 > SPECIAL Well Permit <br /> Pump Inspection By rc D o Date u 7'f(!.: I WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth 1 J ft <br /> COMMENTS <br /> PE S eived Check#/ Amount Date PermiU Invoice# Well ID# <br /> Codes Info B Cash Remitted Service Raiuest# <br /> UIQ 2- 11 D 2 OJ2 WAN. <br /> n <br /> EHD 43-06 WELL!PUMP PERMIT <br /> 4/30/12 <br />