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' r <br /> WELL/PUMP PERMIT <br /> SAN JOActum COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1888 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)488-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 1 I wlrpv CIT/ZP <br /> _ m <br /> CROSS STREET MON FA A1P,N?Z -400-130 PARCEL SIZE A'l-AND USE APPLICA(/TIILtONNt INn <br /> OWNER NAME 1{`v 1 `a' PHONE ZOlt/�,•A/t T/AI W� I/�/`��✓� in <br /> OWNER ADDRESS M 1•,1 V CrTYISTATEIZIP] 1 .I f��//J_\ r/1n /✓�J}n�7 <br /> CONTRACTOR l`1 /� 11 1V G' PNONE car_'`-%/j✓ -I or v <br /> CONTRACTOR ADDRESS A _ CITYISTATE/ZJP ,Cj \ 6 ] <br /> SUBCONTRACTOR _ PHONE <br /> I <br /> LSUBCONTRACTORTOADDRESS CITYISTATE/ZIPSE YC-57 C C-61 D-09 iJ Other NUMBER EXPIRATKIN DATE •-�O' a"V�� <br /> DOME$TIC•••LLLWELL SAMPLING:X Genera l Mineral/Coliform Bacteria(4391)x'1 Dibromochloropropane(4392)1)Arsenic(4393) <br /> INTENDED USE Dom .1--rivate n InlgatlonJAgricultural J Industrial Water Quality Monitoring 1 Soil Sam plinglCharactenzalion <br /> Public Water System <br /> 11 deferent from Owner Waler Syftem Name Cmtacl Name Or Phone Number <br /> TYPE OF WORK New Well Replacement Well 0 Well Alteration/Modlficalion 0 Other <br /> 'New <br /> Wells) X Of wells D Soil Bonngls) a of eo"nar '!Geelechnical a of b—iiii <br /> OuI-Of-Service Well J Out-Of-Servlce Well Renewal a Cross-Connection Repair <br /> New Pump 0 Pump Replacement D Pump Repair (I Raise Well Casing <br /> WELL CONSTRVCT_IONN <br /> Drilling Method XMutl R t'Air Rotary t Auger Cable Tool I Push Point 11 Other <br /> my tl ���/// <br /> Proposed Well Depth V, It Excavation In diameter I;Open Bottom I�,Gravel Pack/Gravel Slze'.VF U_In diameter <br /> Conductor Casing In diameter / Conductor Casing Depth / ft <br /> Well Casing DiameterIL in Thickness/Gauge/ASTM Schad too I]Steel Plastic ^Stainless Steel -I Other <br /> Grout Seal De th R C' Neat Cement(94 Ib bag/5-10 gal water) F Sand Cement sack m;yn gal water <br /> ,zentonite 20%solids) is Other <br /> Grout Placement Method Pumped _. Free Fall I I Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller L. Pump Contractor ^. Other <br /> I I Concrete Pedestal CDlmenslons Width It Length It Thick in D Christy Box U Stove Pipe <br /> PUMP C Submei Turbine .1 Other HP Pump Set R 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 I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MINI;=E NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> f� <br /> SIGNED I��r// II TITLE I DATE O V-�1- YY✓" <br /> I <br /> 51 <br /> F M�Nr <br /> N Fo <br /> q FpaN <br /> COO OAll <br /> Y <br /> MFNT <br /> DEPARTMENT USE ONLY <br /> / r!i C/ �.'. <br /> Application Accepted By f fi" r L Dale / �'J"�� Area r I Employee ID# <br /> Grout Inspection By Date ❑ PECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE Sc Received Check#/ Amount Date Permly Invoice 9 Well IDC <br /> Codes Info Cash Remitted Service Request# _ <br /> L `�L f� _ <br /> �IVlZAPE 7 4 73 <br /> END 43 06 9101;16exw <br /> YIFLL HUMP PERMIT <br /> ll�9GD�8�� <br />