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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1666 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 <br /> NON-REFUNDABLE <br /> PERMIT <br /> ITT �'/'1( CALL 209 953-7697 FFOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> /r <br /> JOB ADDRESS ✓1 / 01 YJ�-7 F r CITY/nP C) <br /> CROSSSTREET01`1 1Ce V APN dZZI-0�O-4i o <br /> //`� PARCEL SIZE � LAND USE APPLICATION# m <br /> OWNER NAME /"\ 1�'L 1: 1 S I 'V"T PHONE <br /> OWNER ADDRESS \� C t'r`C CITYISTATFJAP (V\�Y)4e-C.rA I jCA <br /> Cl 53 <br /> CONTRACTOR �)�I I l 7 1 I t 1 0 r� PHONE �iC��I nnJ k.{C� -//2 7 Za <br /> CONTRACTOR ADDRESS I G i3L-,X - CRY/STATEILP C'LI I T ,y GI S rL% JI <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITYISTAATE/ZJP CIC <br /> LICENSE C-57 C-61 _D-09 - Other NUMBER ✓� ICI✓�5 EXPIRATION DATE -3 <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section_ <br /> INTENDED USE Domestic/Pdvate -Irrigation/Agricultural Industrial _Water Quality Monitoring Soil Sampling/Characterization <br /> Public Water System <br /> If tlifterer4 from Owner: ear ys em C.nt.d N.—or 111 N—Del <br /> TYPE OF WORK YNew Well Replacement Well � Well Alteration/Modification ._:Other <br /> Monitoring Well(s) #of wells -" Soil Boring(s) #of bungs - Geotechnical #of bonnps <br /> Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair <br /> '/,New Pump Pump Replacement - Pump Repair _Raise Well Casin <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary Air Rotary Auger Cable Tool - Push Point Other <br /> Proposed Well Depth ft Excavation _in diameter Open Bottom �K Gravel Pack/Gravel Siz��� in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter-(a in Thickness/Gauge/ASTM Schad d-?c 0 Steel .Plastic f Stainless Steel I. Other <br /> Grout Seal Depth 1 I It Neat Cement(94 Ib bag/5-10 gal water) ;K Sand Cement sack mix/7 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method Pumped Free Fall !Other .J Retardant/Accelerator(name) <br /> PEDESTAL Installed By _ Dnller I Pump Contractor L Other <br /> Concrete Pedestal-Dimensions:Width L ft Length ..2 ft Thick in -Christy Box Stove Pipe <br /> PUMP Submersible Turbine Other HPC Pump Set 2' J 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 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED �7"�/'YC��r�'�'` TITLE Qi C r�.-CS. v)-� DATE <br /> n <br /> J, rr1l <br /> R q yM� <br /> J. <br /> c JU/ 0D D <br /> coq O ?�Z1 <br /> V�RO UqiN C <br /> Tho A ����TY <br /> l <br /> T <br /> �E A MEN4TE�NLY �/�/Application Accepted By ateArea Employee ID# .�~14(! �Z- <br /> Grout Inspection By Date �f� ❑ PECI L Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth O ft <br /> COMMENTS <br /> PE SC Received Check#/ Amount Pe Rolf/ <br /> Codes Info 8 Date Cash Remitted Service Re uest# Invoice# Well ID# <br /> r"-g <br /> o 1 �� tr <br /> EHD 43-08 WELL/PUMP PERMIT <br /> 4/30/12 <br /> '19)0 L4 -951 <br />