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WELL/PUMP PERMIT <br /> SAW JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1666 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)466-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS '(!.�( 'L U l( +dLf f`-1> Crrr21P V/'1-1L- �P J t� D <br /> I,? <br /> CROSS STREET N �r/1� I L/ PARCEL Sig r LAND USE APPLICATION# m <br /> OWNER NAME L! PHONE <br /> OWNER ADDRESS //W S <br /> CONTRACTOR /I PHONE.(—Ql`1�c <br /> CONTRACTOR ADDRESS ''O , CrrY/STATE/ZIPL ^�C[G� L V <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CrrY/STATE/ZIP <br /> LICENSE C-57 C-61 D-09 Other NUMBER a1 y Air _ EXPIRATION DATE/C -)C' <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Rari Section <br /> INTENDED USE Domestic/Privata Irrigation/Agricultural Industrial Water Quality Monitoring Soil Sam pling/Characterizabon <br /> Public Water System <br /> If different from Owner water System Name contaCt Ni8me or Phone Number <br /> TYPE OF WORK New Well Replacement Well F Well Alteration/Modification Other <br /> Monitoring Well(s) #of wells C Soil Boring(s) #of borings Geotechnical #of bonngs <br /> Out-Of-Service Well ❑Out-Of-Service Well Renewal Cross-Connection Repair <br /> ew Pump Pump Replacement G Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary IAir Rotary Auger Cable Tool Push Point Other <br /> Proposed Well Depth ft Excavation in diameter Open Bottom Gravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Sched Steel Plastic Stainless Steel Other <br /> Grout Seal Depth ft Neat Cement(941b bagl5.10 gal water) Sand Cement sack mix/7 gal water <br /> ` Bentonite(20%solids) Other <br /> Grout Placement Method Pumped Free Fall =- Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller X Pump Contractor. Other <br /> Concrete reaestal Dimensions:Width j_ _ft Length _It Thick in Christy Box Stove Pipe <br /> PUMP ubmersible Turbine -Other HP Pump Setfl 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 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION L/,WS. <br /> M Ily)U 24 HO?,,ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)95 -769 <br /> SIGN �— TITLE DATE C..i <br /> I , � <br /> °qQ03p�e <br /> -q Chi <br /> - MFNT <br /> a DEPARTMENT USE ONLY <br /> Application Accepted By ��t�Z-- Date J� Area / Employee ID# ` <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection By 1^"ir"� Date ��11 °W ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#/ Amount Data Permltl Invoice# Well ID# <br /> Codes Info B Cash Remitted Service Re uest# <br /> EHD 4308 WELL[PUMP PERMIT <br /> 4/30/12 <br />