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WELLIPUMP PERMIT <br />SAN .JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 96206 - (209) 466.7420 <br />NON-REFUNDABLE PERMIT <br />CALL(209),953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS 7J�SD � Ty p IL Crrr/ZIP t/4A to C 04 rc If 32k <br />1 q T <br />CROSS STREET S 1iM APN ZA Q - 0 y 0 - 02 y PARCEL SIZE I -I w LAND USE APPLICATION*_ <br />OWNER NAME tiJ Q -CC 1 C MA IN R <br />S -(I M� PHONE G(vS4o2-7�-4, s1 69 0'2 _ <br />OWNERADDRESS 'Lliy w6c.461h-C kloe CITY/STATELP <br />CONTRACTOR LJj{II)S PHONE <br />CONTRACTOR ADDRESS It at Alhtrl 13 CITY/STATEMP /N04 1 /0 /!2) <br />�Jp <br />� <br />Q 37 <br />SUBCONTRACTOR PHONE <br />SUBCONTRACTOR ADDRESS CrrY/SL+T.ATEILP <br />V"OR� <br />LICENSE 57 ❑ "1 ❑ D-09 ❑ Other NUMBER �G�?% EXPIRATION DATE V - 3 2-5 <br />DOMESTIC WELL SAMPLING: D General MinerailColiform Bacteria (4391) 0 Dibromochloropropane (4392) 0 Arsenic (4393) <br />INTENDED USE X Domestic/Private D Irrigallon/Agricullural 0 Industrial ❑ Water Quality Monitoring 0 Soil Sampling/Characterization <br />❑ Public Water System <br />If d"lerant from Owner, Water System Name Conlad Name or Phone Number <br />TYPE OF WORK'X New Well ❑ Replacement Well ❑ Well AlteralloNModKcation ❑ Other <br />0 Monitoring Well(s) A of wells D Sob Bodng(s) s Dr wags ❑ Geotechnical s of bodngs <br />D Out -Of -Service Well D Out -O( -Service Well Renewal 0 Cross -Connection Repair <br />0 New Puma 0 Puma Reolacement n Puma Reoalr n R.I.. Well C..i.. <br />Drilling Method 1<Mud Rotary 0 Air Rotary 0 Auger ❑ Cable Tool ❑ Push Point ❑ Other <br />Proposed Wall Depth 306 11 Excavation /'I r in diameter ❑ Open Bottom )V Gravel Pack/Gravel Size in diameter <br />0 Conductor Casing In diameter / Conductor Casing Depth R <br />Well Casing Diameter (o In Thickness/Gouge/ASTM Schad 7—cra 0 Steel I(Plasbc ❑ Stainless Steel ❑ Other <br />Grout Seal Depth Zl6 U It D Nest Cement (94 Ib bag/5-10 gel water) 0 Sand Cement sack mix/7 gal water <br />X Bentonite (20% solids) 0 Other <br />Grout Placement Method lif Pumped D Free Fall ❑ Other 0 Retardant /Accelerator (name) <br />PEDESTAL Installed By 0 Driller Pump Contractor ❑ Other <br />❑ Concrete Pedestal ODlmsnslans: Width R Length R Thick In 0 Christy Box 0 Stove Pipe <br />PUMP 0 SubmerslbleO Turbine ❑ Other _ HP Pump Set it Standing Water Level 11 <br />1 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 />M M 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 9953.7697 <br />SIGNED 11—- TITLE0 &A w / DATE 2L'30 — Z 1 <br />rti <br />RW yr <br />rf-PkRfMENT UA EC/N L�Y�i <br />Application Accepted By ate v/ Area Employee 7 <br />Grout Inspection B Date ❑ PECI L Well Permit <br />Pump Inspection By Date ❑ WAIVER Received <br />So9 Boringpeclion By Date Constructed Wall Depth ft <br />COMMENTS OI'V LUL°L'T <br />EH043-M be1/1e <br />