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0 WELL/PUMP PERMIT <br /> SAN JOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 <br /> NON-REFUNDABLE PERMIT 4j, CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS Crrv/ZIP <br /> D <br /> p 1', � o <br /> CROSS STREET 2 D4 <br /> APN 0 00 3 PARCEL SIZE LAND USE APPLICATION <br /> OWNER NAME � PHONE <br /> OWNER ADDRESS �®l��/��j CrrY/STATE21P SP�Jr'/ :*4 <br /> CONTRACTOR a®(�►/���/�'yS l/JZ/��'��"/���X — PHONE <br /> � <br /> CONTRACTOR ADDRESS I ` jr B3C �"��J CITY/STATE21P D'/� <br /> SUBCONTRACTOR " f1�^� J'� PHONES'Z lfI <br /> SUBCONTRACTOR ADDRESS CrrY/Y/STATE/ZIP <br /> LICENSE -57 -61 "D-09 Olhe! NUMBER_e99t `SZ— E%PIRATION DATE l <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section_ <br /> INTENDED USE Domestic/Private Irrigation/Agricultural Industrial ,Water Quality Monitoring Soil Sampling/Characyy��7���V��I1 c1�! <br /> Public Water Sy em RFZP- �r <br /> If different from Owner. Water System Name contact Name or Phone NUMDar ED <br /> TYPE OF WORK New Well eplacement Well Well Alteration/Modification Other NA 0 <br /> dol borings S+q A of tx)dngs <br /> Monitoring We2015 <br /> #of wells Soil Borings) Geotechnical N.tn"QU1N CO <br /> Oe Pfumervice Well Out-Re lacement Pum�Re alit a Well Renewal CrOSS-ConnecRaise Well Casing <br /> Repair NTy <br /> HEA T I�A ENTAL <br /> WELL CONSTRUC&N MR <br /> Drilling Method ud Ro�ryy,, Air Rotary Auger Cable Tool Push Point Other / <br /> Proposed Wel Depth �X f ft Excavation in diameter Open Bottom ravel PacWGravel Size in diameter <br /> Conductor Casing In diameter / Conductor Casing Depth it <br /> Well Casing Diameter__2 In Thickness/Gauge/ASTM Schad� f i Steel�lastic I Stainless Steel Other <br /> Grout Seal Depthsc-'" it Neat Cement(94 Ib bag/5-10 gal water) Sand Cement sack mW gal water <br /> 'Bentonite(20%solids) 1 Other <br /> Grout Placement Method Pumped i Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller Pump Contractor, , Other <br /> I Concrete Pedestal iDimensions:Width_3 it Length=It Thick=in ":Christy Box Stove Pipe <br /> PUMP Submersible-:Turbine Other HP Pump Set —ft Standing Water Level ft <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 /> MINIM U AD E NOTICE REQUIRED FOR INS _ECTIONS-PLEASE CALL(209)95317697 <br /> SIGNEDTI / � DATEPal A& <br /> 3 — e G <br /> VIM <br /> 44 <br /> t <br /> -1Z14Z-i- ' <br /> G - - <br /> � G - <br /> �i ?, h <br /> ;.0 C"I�vl DEPARTMENT USE ONLY <br /> Application Accepted Date Area 11 Employee IDN I- <br /> � <br /> Grout Inspectio Date Z ❑ SPECIAL Well Permit <br /> Pump Inspection �� Date ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Chec Amount Date Pet' <br /> Invoice# Well ID# <br /> Codes Info B ash Remitted Service Re uest# <br /> can•a.na i WELL/PUMP PERMIT <br />