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WELUPLIMP PERMIT <br />SAN .I')AOU!N.COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 18Ci8 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT CALL (209) 953-7697 FOR INSPECTIO14S EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS 0 �_ CITY/ZIP�CSMI NS l <br />CROSS STREET C.,Y "� APN ©3 3 ` 14 Sy ' 00 PARCEL SIZE `�V'"� v LAND USE APPLICATION # <br />OWNER NAME 'f A U'V-, I 1 ` Gt'r W\_5 _ PHONE <br />OWNER ADDRESS �� Vn� t �� �S I __. CITY/STATE/ZIP <br />CONTRACTOR (�W `\ �� r \ I y —L- PHONE <br />CONTRACTOR ADDRESS I \01 b-erj ( _- CITY/STATE/ZIP 46 / C,, "15,3,5 -7 <br />SUBCONTRACTOR <br />SUBCONTRACTOR ADDRESS <br />LICENSE< -57 1 C-61 I D-09 I Other <br />PHONE <br />CITY/STATE/ZIP <br />NUMBER '1 Y� ��� EXPIRATION DATE 7 <br />GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br />INTENDED USE Domestic/Private Irrigation/Agricultural Ij Industrial I Water Quality Monitoring , Soil Sampling/Characterization <br />Public WaterSystem <br />If different from Owner: Water System Name Contact Name or Phone Number <br />TYPE OF WORK "New Well ❑ Replacement Well I Well Alteration/Modification i I Other <br />F-1Monitoring Well(s) # of wells i Soil Boring(s) If of borings I Geotechni�— f <br />❑ Out -Of -Service Well Out -Of -Service Well Renewal 1i Cross -Connection Rep . <br />F1 New Pum Pum Replacement ! Pum Repair 1 Raise Well Casing�i <br />WELL CONST CTION <br />Drilling Method Mud Rotary I Air Rotary i Auger -I i C/Ple Tool I Push Point I I Other <br />Proposed Well Depth_ :�(-i ft Excavation in diameter Open Bottom I ! 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 _I Plastic i_I Stainless Steel Other <br />o <br />Grout Seal Depth r') ft I Neat Cement (94 Ib bag/5-10 gal water) !J Sand Cement /013 sack mix/7 gal water <br />Bentonite (20% solids) Other <br />Grout Placement Method\,seumped 1 l Free Fall Other Retardant / Accelerator (name) <br />PEDESTAL Installed By i Driller 11 Pump Contractor I Other <br />i Concrete Pedestal Dimensions: Width ft Length It Thick in i Christy Box i Stove Pipe <br />PUMP Submersible Turbine Other HP Pump Set ft 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 224 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />SIGNED �L/1)�J TrrLE r1 I ` lmr�.,,,. _ DATE/ --2-1-1 <br />DEPARTMENT USE ONLY <br />Application Accepted By �.�. ( . Date D ZS C t 3 Area amt L� Employee ID# <br />Grout Inspection By Date ❑ SPECIAL Well Permit <br />Pump Inspection By <br />Soil Boring Inspection <br />COMMENTS 1 e 1 <br />Date ❑ WAIVER Received <br />Dates T Constructed) Well Depth ftft <br />JA 0 T41 root � r'wc -f C <br />T <br />m <br />D <br />0 <br />0 <br />m <br />U) <br />to <br />PE <br />Codes <br />Sc <br />Info <br />Received <br />B <br />heck#/ Amount <br />Cas Remitted <br />Date <br />Permit/ <br />Service Request # <br />Invoice # Well ID# <br />a�38 ;�L: a> <br />23 <br />5(�FE <br />11 <br />EHD 43-06 WELL /PUMP PERMIT <br />4/30/12 <br />