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WELUPUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1 m,8 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL <br /> � 209 953-7697 FOR INSPECTIONS ) EXPIRES 1 YEAR FROM DATE ISSUED <br /> "LZ 660 IVO%A0 h 1�' G. 1 n G7 t°/7 C �Z �-v m <br /> JOB ADDRESS ii {���• CITY/ZIP D <br /> C cl ^ 1' 0`� - � D- 13 PARCEL SIZE � <br /> CROSS STREET �d A APN > LAND USE APPLICATION# m <br /> U) <br /> (jeraiI F <br /> OWNER NAME ` U rj- PHONE C <br /> OWNERADDRESS 9'-,, �a 7� ivt _ CITY/STATE/ZIP/__,md,n � 5i q✓G2J' <br /> CONTRACTOR Mwse/llisAlbers <br /> (D��\,SKS --:��_. PHONE <br /> C1S�Z� fg2,9 5 <br /> CONTRACTOR ADDRESS I I^I / �I V P rS f�_J CITY/STATE/ZIP M�-pJ7 d / C� ! f3✓ -7 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITYC// V 4STATE/ZIP <br /> LICENSE �(C-57 C-61 D-09 ❑ Other NUMBERI V - EXPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township __ Range Section <br /> INTENDED USE ❑ Domestic/Private rrigation/Agricultural L.I Industrial Water Quality Monitoring Soil Sampling/Characterization <br /> n Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK ,New Well Replacement Well ❑ Well Alteration/Modification ❑ Other <br /> ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings Geotechnical +of borings <br /> ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal i Cross-Connection Repair <br /> F] New Pump i Pump Replacement ❑ Pump Repair i Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Methods Mud Rotary Li Air Rotary Auger i Cable Tool I! Push Point Other ,� ` <br /> Proposed Well Depth SQL) ft Excavation F in diameter Open Bottom h Gravel Pack/Gravel Size in diameter <br /> ❑ Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter�z in Thickness/Gauge/ASTM Sched 2-66) Steel Plastic F Stainless Steel Other <br /> Grout Seal Depth Sn ft Neat Cement(94 Ib bag/5-10 gal water) i I Sand Cement sack mix/7 gal water <br /> Bentpnite(20%solids) Other <br /> Grout Placement Method.',/ <br /> Pumped Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By i Driller Pump Contractor Other <br /> ❑ Concrete Pedestal Dimensions:Width ft Length ft Thick in Christy Box Stove Pipe <br /> PUMP ❑ Submersible[_ Turbine Other HP Pump Set It 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 /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL(209) 953-7697 <br /> SIGNED —� "T LE (/�' DATE <br /> III ICY" <br /> s <br /> i <br /> 4 <br /> ( P <br /> 1T& Nj` <br /> C ` <br /> ol <br /> .0 <br /> C <br /> V J <br /> t <br /> AJ <br /> DI <br /> _ <br /> Sim N A <br /> R <br /> J- <br /> T IViENT USE ONLY <br /> Application ccepted By Date u V ` "tel 1 Area Employee ID# <br /> Grout lrapmb&@y have expired without— Date SPECIAL Well Permit <br /> Pumr ske6i(q -,N ep[rnI tP.� er insDac' -� Date 1 1 WAIVER Received <br /> Soil BoringFmu li 22, 1a ' rjvliginn Date Constructed Well Depth ft <br /> COMMENTS JJ <br /> PE SC Receivedheck Amount Date Permit/ Invoice# Well ID# <br /> Codes Info Cash Remitted Service Request# <br /> EHD 43-06 WELL/PUMP PERMIT <br /> 4/30/12 <br />