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�xl,;hal Scdn yfyli� �'� <br /> WELL/PUMP PERMIT <br /> Sm J0AoutNCDUNw ENVIRONMENT <br /> I/y/.,HEALTNDEPARTMENT 1868 EAST HA2ELTON AVENUE-STOCKTON CA 95205-(209)46&3420 <br /> NON-REFUNDABLE PERM1IT t/J1 J ��SCALL 209/n953-XA766n97 FOR INSPECTIONS EXPIRES 7 YEAR FROM DATE ISSUED <br /> JOB ADDRESS �SI 2, LLA^%n/1 A A"L Cmrr p-aci&M1 l <br /> 1\\�,�.,(� (���//JJ 0 <br /> CROSS STiEET //�'� ((//-- APN.0 'I IIJ•LU-I PARCELSRE�LLAND USE <br /> APPPPLLIICCATION# <br /> OWNERNAME CA tC//I4 tCf PHONE O"— I.p� ��:Jr] N <br /> OWNER ADDRESS UVI ML CITWSTATFILIP JOL rune. <br /> CONTRACTOR CSS+Ip ('aJti.s�'n..y�lu/,�n Injaf bird ff !1 — PHONE 2L4 Cif g_ ,,C-7t� <br /> CONrRpLTDgAODPESS 4t va <br /> _' VVI SyIV'LY, /��/ `�I CM/STATE21P r�C <br /> SUBCONTRACTOR I R PHONE rt,6 W <br /> SUBCONTRACTORADDRESS I R CTTVISTATERIP N 1r �/f 1 <br /> UCENSE CS/ L C$1 11D-09 ❑Other NUMBER�� EXPIRATION DATE /—O <br /> GEOGRAPHICAL INFORMATION: Coordlnatee X Y - Township— Range_ Seaton_ <br /> INTENDED USE DomesticlPrlvate ]irrigation/Agricultural ❑Indusldal 7 Water Quality Monitoring C Soil Sampling/Characterization <br /> U Public Water System <br /> Ifddfienmtfmm Ormea m ma Q0rhsANa=orPWrwNLMbRr <br /> TVPEOFWORK 3,N8W Well L Replacement Well U well AllerafloNModiFlcalion UOther <br /> ❑Monitoring Well(s) Is of wells ❑Soil Boring(s) #d Izerm ❑Geotechnical #of Endres <br /> ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal D Cross-Connection Repair <br /> U NEW PUMP L PUMP Replacement U Pump Repair U Raise Well Casino <br /> WELL CONS TH)COON <br /> Drilling Method 0 Mud Rota IT RR aft C Auger ]Cable Tool ❑Push Point ❑ Other <br /> Proposed Well Depth W Excavation t) —_in diameter U Open Bottom U Gravel PaddGlavel Size in diameter <br /> nCondos rCasing in diameter / Conductor Casing Depth v ft Well Casing Diameter in idm9es/GaugWASTM Schad n Steel ^Plastic n Stainless Steel n Other <br /> Grout Seal Depth C Neet Cement(94/b bag/5-10 gal wafer) 0 Sand Cement' sank mW7 gal water <br /> rbentonile(20%solids) L Other <br /> Grout Placemen Method*(Pumped ❑Free Fall C Other ❑ReteManl/Accelerelor(name) <br /> PEAS Installed By ]DTlller C Pump Contractor ] Other <br /> ❑Concrete Pedestal ODhnenslona Wdlh_It Length ftThicK In ❑Christy BOK ❑Stove Pipe <br /> PUMP ❑BUbmass ibla turbine C Other HP Pump Bet ft Standing Water Leval ft <br /> I HEREBY CE T I HAVE P PARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN CO O D NANCES, ATE WS, AND RULES AND REGULATIONS. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRE CT E WITH CAL RNIA CON CTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKE C EN <br /> HOU N CE REQUIRED FOR <br /> INSPECTION PLEASE CALL(209)953-7697 <br /> SIGNED TITLE IQ I M=�'y��yyL= DATE <br /> PAYMENT <br /> RECEIVED <br /> 2011 <br /> M'JOAQUNVIRONIN COUNTY <br /> TH DEPARTMENT ARTMENT <br /> DE RTMENA,T#��1��1,�ssS'',�E,,tI11 O,, N��LY (n/(/�/r J �r�� � <br /> Application Accepted Date Area 'I� 1 Employee ID#I <br /> Grout Inspection By Data --�`�` �'�' ❑ FECAL Well Permit <br /> Pump Inspection By Data ❑ WAIVER ReCBIVed <br /> Soil Boring In ecti n By Date Con�.�truyycterd Wel�l,D�ept�h ft <br /> COMMENTS )aW 41 , Yrl�- (drY-tfGGtLr <br /> PE SC Received QZLetAmount Date Permit/ Invoice# Well IW <br /> Codes Info a Cash Remitted Servl.Request# <br /> ( 1°J * ICD4 u Sem 5 <br /> EHO 43-06 WELL HUMP PERMIT <br /> V 2 <br />