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WELLIPUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1866 EASTHAZELTON AVENUE-STOCKTON CA 95206-(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL`(2209 953.7697 FOR INSPECTIONS EXPIRES'I YEAR FROM DATE ISSUED <br /> Joe ADDRESSTI _ CIi YIZIP_ /^ <br /> r — 7 <br /> CROSS STREET�)�1�>.t!^li 4 T �5 ')APN 1 �� ��-_3 � <br /> _ J !1)�%1' I'_� PARCEL SIZE LAPID USE APPLICATION 11 A <br /> OWNER NAME PHONE <br /> OWNER ADDRESS t` 1 1..�L;-r'{�Jrr �i - C7TY/STATEJZIP <br /> CONTRACTOR i y~I PHONE l0 <br /> CONTRACTOR ADDRESS / .7 -5 dill:-.V c:GtJ L.r� #IIT/STATEI21P }:'" ���J'�f (I/a `Il7 l7U <br /> SUBCONTRACTOR _Jib) 3Y-I 11 r rtJi=' PHorJE <br /> SUBCONTRACTOR ADDRESS .SLOG �i eta-ll— IL LD CITY/STATE/ZIP <br /> LICENSE D C-57 ❑C-61 7 D-09 =Other �- NUMBER ExPDTATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range_ Section_ <br /> INTENDED USE _I)0MCStICIPIIVOIC ]Irrigallon/Agricultural 9Y�ndustdal D Water Quality Monitoring O Soil Sampl-mg/Characlerizatlon <br /> Public Water System <br /> ( Irmf�r°maomUvror. er y °m mq on c ama°r, a um__r I Vii. <br /> TYPE OFWORrc =New Well =ReplacemenlWefl 0Wall Alturation/ModlllcatiOnG;Other{jf.'a :nv7 440 Gti = <br /> W CD <br /> _MorJlOdng Wells) R of wells U Soil Boring(s) w er don�y. U Geolechnkal #°f tiO �• <br /> W-01-SeM ❑OM <br /> ce Well ui-Or-Sece We4 Rer:evial O CTeise-Conraclson Repair <br /> New Pum - Purnp Replacement n Pump Repair n Raise Well Casino <br /> WELL CONSTRUCTION <br /> Drilling Method -Mud Rotary �(Air Rotary -�Auger n Cable Tool n Push Point F Other CSO <br /> Proposed Well Depth '75 It Fx avelion FI diameter D Open Bottom O Gravel Pack/Gravel Size In diameter <br /> _Conductor Casing In diameter / Conductor Casing Depth 1`1 CD <br /> ■ A <br /> Well Casing Diameter_In Thickness/Gauge/ASTM Sched ]Sleel D Plastle O Stainless Steel O Other Com►' <br /> Grout Seal Dep h A U Neal Cement(941b bag/5-10 gal water) U Sand Cement stick mixt7 gel water C CL <br /> CD <br /> J'-caGnlonits(20%solids) 13 Other <br /> Grout Piacamedt Method ❑Pumped D Proo Fall D Other 7 Retardant/Accelerator(name) <br /> PEDESTAL Installed By L-Ddllor U Pump Contractor _ Other <br /> -Concrete Pedestal-Dimensions;Width_R Length it Thick In Christy Box -IStove Pipe <br /> PUMP -Submsrsiblar Turbine D Other HP Pump Set R Standing Water Level fl CJY <br /> 9 il <br /> I HEREBY CERTIFI' AT I HAVE PREPARED TMS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN , <br /> JOAQUIN COU OR NANC LAWS,AND RULES AND REGULATIONS. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS '.� r � <br /> CURRENT A b ACTIVE WITH THE CALIF RNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL LZ <br /> ,lORiCERS w::IPE:JSATION L:,WS. � <br /> MI _M 2 'HOUR ADVANCE NOTICE REQUIRED FQR INS PEGTIOJV EASE CALL(209)9 3-/76 7 <br /> STONE 't- / TRLE I� Y.1, 1 DA7E I <br /> -41 <br /> PERMAITI.. ' ' —LL <._il J <br /> F`,retia may.h ., f AY�n vE® <br /> RECEIby�:tl�'�t" .Irn3i r JAN 0 6 2015 <br /> JpApU1N COUNT; <br /> ENVIR�O pACOUNT t <br /> ALTH <br /> DEPARTMENT USE ONLY )) <br /> Application Accepted By Date t-I :-.I � � Area '-'^<I '" i Employee ID+R <br /> Grout Inspection By Dela t Q SPECIAL Well Permit <br /> Pump Inspection By Data E) WAIVER Received <br /> Soil Boring Inspectlon By Date Constructed Well Depth R <br /> COMMENTS <br /> PE SC Received heck#/ Amount WeII1D#Date rrl <br /> Codes Into B Remitted Se",PaRmll!e uest# Invoice <br /> (S (Z.1- 11 � <br /> E!D 43-M Vv�ctL A'U,tP PER N IT <br /> 4r°ll2 <br />