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WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE • STOCKTON CA 95205.6232 (209) 468-3420 <br />N -REFUNDABLE PERMIT WWW.S OV.Of /ehd EXPI <br />/RES 7 YEAR FROM DAATTEE 1(55UED <br />ADDRESS iop�� - t v J�-�� �j CITY11/�+LyPc ` q,(` 1 <br />SS STREET efr r fJ�C \ ,t7 '_AAPN /1 n-() 1 "_PCZ PARCELSIZE I.LAND USE APPLICATION<# (d <br />IER NAME � KYR- �"` Oj( `� �� v PRONE <br />r <br />OWNER ADDRESS (,-91 /' �: � Irll I:2 `� 1 CITYISTATE/ZIP <br />CONTRACTOR l 1/' YLB_e ���'I/`/ll,��/y`,,, cV�Lt.�1I,.��I V �PHO(NE( UCI '�l�[�E b/�,}1,,Qow <br />CONTRACTOR ADDRESS U "-Flax l ` /L J CIN/STATE/ZIP t �-- �y� 4- ✓' �L.' 1 [ -�y <br />SUBCONTRACTOR/CONSULTANT t j PHONE <br />SUBCONTRACTOR/CONSULTANT ADDRESS CIN ZI <br />/STAT P C{ <br />LICENSE A C-57 C C-61 a D-09 'J Other NUMBER�� EXPIRATION DATE ` t v <br />BILLING PARTY: OWNER CONTRACTOR SUBCONTRACTOR/CONSULTANT <br />DOMESTIC WELL SAMPLING: General MineraUColiform Bacteria (4391) Dibromochloropropane (4392) Arsenic (4393) <br />INTENDED USE omestic/Private n Irrigation/Agricultural - Industrial C Water Quality Monitoring . i Soil Sampling/Characterization <br />Public Water System <br />If different from Owner Water System Name Contact N— or Phone Number <br />TYPE OF WORK )(New Well G Replacement Well i Well Alteration/Modification ❑ Other <br />D Monitoring Wells) # of wells D Soil Borings) � Geotechnical <br />Out -Of -Service Well D Out -Of -Service Well Renewal :1 Cross -Connection Repair <br />New Pumo n PumD Reolarement C Pump Repair u Raise Well Casing <br />filling Method ,Mud Rotary I I Air Rotary D Auger C Cable Tool Push Point C Other <br />-oposed Well Depth �ft Excavation in diameter _ Open Bottom D Gravel Pack)Gravel Size in diameter <br />0 Conduct r Casing in diameter ! Conductor Casing Depth ft <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched_`�T)R 2, D Steel Xlastic ❑ Stainless Steel ! Other <br />Grout Seal Depth ft D Neat Cement (94 lb bag15-10 gat water) 0 Sand Cement sack mix17 gal water <br />Ix Bentonite (20% solids) -I Other <br />rout Placement Method KPumped D Free Fall D Other D Retardant / Accelerator (name) <br />PEDESTAL Installed By C Driller Pump Contractor D Other <br />u Concrete Pedestal DDi a sions: Width R Length ft Thick In C Christy Box n Stove Pipe <br />PUMP Submersible'-- Turbine C Other HP Pump Set ft Standing Water Level 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 1 AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATION LAWS. <br />MINI Ue U ADVANCE NOTICE REQUIRED FOR INSP (7TTIIONSS - PLEASE CALL (209) 953-7697 'l <br />SIGNED----4444��--- �- TITLE DV'` ' DATE -0 <br />_N <br />D <br />fn <br />M <br />V ' <br />60 <br />DEPARTMENT <br />/ SE ONLY <br />Application Accepted By 'de Date 7 70ZO Area Employee ID* 51k <br />Grout Inspection By ( D le 0 PECIAL Well Permit <br />Pump Inspection By fh�jl a�t WAIVER Received <br />Soil Boring Insp ction By Date Constructed Well De h © 0 ft <br />SAM NTS O Z t �CO <br />Received <br />W <br />Invoice # I Well ID# <br />I - fes/ qO �% �Q �j�M 'LL (PUMP PERMIT <br />/y �EH043-06 61111//20018 V' ,' 010 <br />lid44-0,W, �_//�� �e;-2MM///"��`D{c ti D,w L k;(& <br />A �_ I '0' <br />"W"jw* f 14I S i�L��- �✓ �wts `� Kt%/ I �' l <br />Ot ��vq oYe bA4 A-� <br />II 20 �r LjT9;-�' <br />S -�' VW A� <br />q "� Lo6,9s wt?✓%' T -d -!o a At%lou. I l -f kp _T'1� <br />