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I. <br /> WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232(209)168-U20T <br /> NON-REFUNDABLE PERMIT rWWW.s Qv.ol /ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> Joe ADDRESS 'TC^,^rl,1 4- CITY(L �'P `C 6j Iv) t C/ i <br /> CROSS STREET C--4 f Q-\A 12, 7 APN001-4 ✓D-b o PARCEL SIZE'"1 /-1 I LAND USE APPLICATION# <br /> OWNER NAME A I l( U i �- 2 C PHONE ;?0"1 <br /> OWNER ADDRESS \3 1 .�`I 0ct`' -Vo'n 1 Hrzo q I n CITYISTATEIZJP J t' 7cA q <br /> CONTRACTOR �t} 1 11z7 1 1, n /PHONE I L"'I ---2 7 7- <br /> CONTRACTOR ADDRESS �' L 47 C X cn-Y/STATEaip L n ' �- I CA <br /> SUBCONTRACTOR/CONSULTANT PHONE <br /> SUBCONTRACTOR/CONSULTANT ADDRESS CITYISTATEEILP <br /> LICENSE )�,C-57 x -61 D D-09 C Other NUMBER 2�I6 <br /> I b EXPIRATION DATE 7— _ 2 <br /> BILLING PARTY: D OWNER CONTRACTOR G SUBCOWRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING:G General Mineral/Coliform Bacteria(4391)0 Dibromochloropropane(4392)0 Arsenic(4393) <br /> INTENDED USE ,DomestidPrivate D Inigation/Agricultural ❑Industrial -1 Water Quality Monitoring ❑Soil Sampling/Characterization <br /> 0 Public Water System <br /> If different from Owner'. Water System Name Contact Name or Phone Number <br /> TYPE OF WORK ' New Well 0 Replacement Well n Well Alteration/Modfication D Other <br /> ❑Monitoring Weil(s) #of wells O Soil Boring(s) s of bonny` 0 Geotechnical s or boring. <br /> 0 Out-Of-Service Well 0 Out-Of-Service Well Renewal u Cross-Connection Repair <br /> ew Pum i Pump Replacement 0 Pump Repair O Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method`k Mud Rotary Fi Air Rotary ❑Auger 0 Cable Tool D Push Point 0 Other <br /> Proposed Well Depth 3. C i ft Excavation ) in diameter -Open Bottom -)k Gravel Pack/Gravel Size )f a _ in diameter <br /> u Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter (�^, in Thickness/Gauge/ASTM Sched 900 ❑Steel YPlasfic 0 Stainless Steel 0 Other <br /> Grout Seal Depth )(T _ft D Neel Cement(94 lb bag/5-10 gal water) "1 Sand Cement I V 7 sack mixn gal water <br /> ❑Bentonite(20%solids) D Other <br /> Grout Placement Method umped 0 Free Fall ^Other i!Retardant/Accelerator(name) <br /> PEDESTAL Installed By L rifer 0 Pump Contractor ❑ Other <br /> i,Concrete Pedestal ODimensions:Width S ft Length ft Thick in n Christy Box 0 Stove Pipe <br /> .PUMP YT Submersible❑Turbine C Other HP Pump Set ('1 > It Standing Water Level ISG ft <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 /> l K-$;it 3i R,'DVG,'NCE NOT ICE PE'?UIRED FOR Ilr��SPECTIO NS-PLEAS CALL(140)9r;5..7Ee:! } <br /> SIGNED TITLE �-'* C e r DATE <br /> rn <br /> 1 11 7J <br /> 0 <br /> PAYME <br /> RECEI <br /> OCT 0 6 <br /> n <br /> SAN JOAQUIN <br /> ENVIRONM <br /> HEALTH DEP <br /> 4�' <br /> � <br /> FFTF <br /> PACRTMENT UY <br /> Application Accepted By / Date �Zzl1 Area-`t�+'�— Employee ID#J` "" — p"-U��2 <br /> Grout Inspection Ely L>Ie,rCtd Lzndl Ail Dete l6'� 1917 LI LI SPECIAL WBII Permit <br /> Pump Inspection By Date C WAIVER Received <br /> Soil Boring Inspection By D to Constructed WellDepth <br /> COMMENTSU c— I.cll' <br /> PE Sc Received Check#/ Amount Permit) <br /> Codes Irito casth Re d D Service R uest# Invoice# Well IDN <br /> 'ramer to a� <br /> r.143a6 6111/2079 WELL IPI/MP PERMIT <br /> /3277,3 04� <br />