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WA LLIP��96V F PFERR u <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTi-I DEPT 9868 Cast Hazelton Avenue-STOCICrON CA 95205-6232 - (209) 468-3420 <br />CALL (209) 953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED <br />JOB ADDRESS 2'3M Clr`/ZIP L.-JC4 /49A /-e. / J 322e) <br />CROSS STREET ��Y`� <br />(7 MC'NO ` " APN 2y1-3 �ZL�L_ <br />p ` PARCEL SIZE � / LAND USE APPLICATION# <br />OWNER HAME 1--r A,%..- 1�1k���1\ TOVtACl (2o'� j_AA4 CO- PHONE 6 p <br />52-2 & <br />� QQ <br />OWNER: DDRESS Z3 ZS 1 o hrPT� {t° CITY/STATEIZIP�«/O; % C,, `91,320 <br />CONTRACTOR mAlfllif D)111,nN1{ C PHONE/�-! c <br />CONTRACTOR ADDRESS t ► r�s CITYISTATE/ZIP /m OA-r{L� r, �j3f 7 <br />SUBCONTRACTOR <br />SUBCONTRACTOR ADDRESS <br />LICENSE `gC-57 ❑ C-61 ❑ D-09 ❑ <br />CIT(/STATE/ZIP <br />NUMBER U'?? <br />PHONE <br />EXPIRATION <br />GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Sec <br />INTENDED USE ❑ Domestic/Private )KIrrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring 0 Soil Sampling/Characterization <br />❑ Public Water System <br />If different from Owner: Water bystom Name Uontact Name or Phone Number <br />"TYPE OF WORK New Well 0 Replacement Well ❑ Well Alteration/Modification ❑ Other <br />0 Monitoring Well(s) # of wells ❑ Soil Boring(s) # of borings ❑ Geotechnical <br />❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br /># of borings <br />❑ New I -UM ❑ 1-ump Keplacement ❑ I-LIMPi-ie air u Kalse vvell uasin <br />'NELL CONSTRUCTION <br />Drilling Method )KMud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other <br />Proposed Well Depth15PQ! ft Excavation in diameter ❑ Open Bottom )r Gravel PacldGravel Size Ob in diameter <br />❑ Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter in Thickness/Gauge/ASTM Schad 0.250 XSteel ❑ Plastic ❑ Stainless Steel ❑ Other <br />Grout Seal Depth ft ❑ Neat Cement (94 Ib bag/5-10 gal wafer) ❑ Sand Cement %O �� 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 Pump Contractor ❑ Other <br />❑ Concrete Pedestal Dimensions: Width ft Length f: Thick in ❑ Christy Bou ❑ Stove Pipe <br />PUNIP ❑ Submersible❑ Turbine ❑ Other I -IP Pump Set ft `Standing Water Level ft <br />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 />CURRE ND ACTIVE WITH THE CALIFORNIA CONTRACTORS :STATE LICENSE BOARD AND THAT .I AM IN COMPLIANCE WITI-1 ALL <br />p00E K OMPENSATION LAWS. <br />MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS 9 <br />� kZ � TITLE—P,- r- d, 1 /F•! DATE <br />19 (� <br />- - � Well <br />1 <br />►,era <br />A <br />PEE d oA l C <br />V, <br />m <br />A <br />m <br />N <br />Soil Boring Inspection By <br />COMMENTS <br />Date <br />Constructed Well Depth <br />tl-t <br />PE <br />Codes <br />Sc <br />Info <br />Received <br />By <br />Chccic'l/ <br />Cash <br />Amount <br />Remitted <br />Date <br />Permit/ <br />Service Re uest,. <br />Invoice # Well ID# <br />G <br />n 6"a <br />PE <br />VVIMIr <br />DEPARTMENT USE ONLY <br />^ <br />Application Accepted D Date <br />Area Employee ID# <br />Grout Inspection By Date <br />PECIAL Well Permit <br />Pump Inspection By Date <br />WAIVER Receives <br />Soil Boring Inspection By <br />COMMENTS <br />Date <br />Constructed Well Depth <br />tl-t <br />PE <br />Codes <br />Sc <br />Info <br />Received <br />By <br />Chccic'l/ <br />Cash <br />Amount <br />Remitted <br />Date <br />Permit/ <br />Service Re uest,. <br />Invoice # Well ID# <br />G <br />n 6"a <br />PE <br />VVIMIr <br />EI -ID 43-00 WELL /PUMP PERMIT <br />8104/08 <br />