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CITY/STATE/ZIP <br />PHONE <br />SUBCONTRACTOR/CONSULTANT ADDRESS CITY/STATE/ZIP <br />JOB ADDRESS S60 eD, CrraZie Prelly-NR!) 96—Z3f, <br />CROSS STREET VV.-W*11- .C, ke--- AP N C rf- --CV — 56 PARCEL SIZE LAND USE APPLICATION # <br />OWNER NAME Co51-eara-tc43 Ive.. 1066bZei1telE_ t)01&-t-YPHONE <br />OWNER ADDRESS ''-‘)44't t CITY/STATE/ZIP <br />CONTRACTOR j715.0-,V9-11/4-, L04.,.tp, _ P41411.1 71E5 DCLEICMAZ_ PHONE /I:?#' 1c —&:& <br />CONTRACTOR ADDRESS <br />SUBCONTRACTOR/CONSULTANT <br />ei-VUE <br />LICENSE C-57 C-61 0-06 Other <br />BILLING PARTY: ?CONNER <br />CONTRACTOR SUBCONTRACTOR/CONSULTANT <br />NUMBER <br /> <br />EXPIRATION DATE <br />ft Thick in Christy Box Stove Pipe <br />PEDESTAL Installed By Driller Pump Contractor Other <br />Concrete Pedestal Dimensions: Width ft Length <br />ft Pump Set ft Standing Water Level PUMP HP Submersible Turbine Other <br />Water System Name Contact Name or Phone Number If different from Owner <br />Replacement Well <br /># of wells <br />New Well <br />Monitoring Well(s) <br />Out-Of-Service Well <br />New Pump Pump Replacement <br />Geotechnical <br />Cross-Connection Repair <br />Raise Well Casing <br />Well Alteration/Modification Other <br />Soil Boring(s) # of borings <br />Out-Of-Service Well Renewal <br />Pump Repair 41110451IF <br />Grout Placement Method Pumped Free Fall Other Retardant Accelerator (name) <br />But borings <br />WELL CONSTRUCTION <br />Drilling Method Mud Rotary Jr Rotary Auger Cable Tool Push Point Other <br /> <br />Proposed Well Depth ft Excavation in diameter Open Bottom Gravel PackiGravei Size <br /> <br />Conductor Casing In diameter / Conductor Casing Depth It <br />Well Casing Diameter In ThIcitness/Gauge/ASTM Sched Steel Plastic Stainless Steel Other <br /> <br />Grout Seal Depth ft Neat Cement (94 lb bag/5-10 gal water) Sand Cement <br />Bentonite (20% solids) Other <br />sack mix/7 gal water <br />TYPE OF WORK <br />In diameter <br />INTENDED USE Domestic/Private Irrigation/Agricultural Industrial Water Quality Monitoring Soil Sampling/Characterization <br />Public Water System <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 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />SIGNED •••r•--1(ri.TC \ t f Ar` CC DATE :S/V2-1 Time <br />e <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 East. HAZELTON AVENUE - STOCKTON CA 95205 -6232 (209)468-3420 <br />NON-REFUNDABLE PERMIT WWW.SigOV.Orgiehd EXPIRES 1 YEAR FROM DATE ISSUED <br />DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic (4393) <br />11111111101111111111111011661611 ‘k ..., mymnammum wrim • mummwm• Imitermaffammom ummedmommomMarammummommamummummimmumm r mommimmummoimmummmrmirms mummiummumm <br />iLl 1111111111111,1112=1111 1111411111111111 minnow ummkepamormini mis wirturnaumm <br />11111111111191alliilailiiiiiiiiiiiii mg__ ' r, AZAMMINIMEMINUMMINIMMEMEMMIMM <br />0011/Ii111111 NMI& mmlimmommilmn111111 mows- , <br /> <br />Grout Inspection By Date <br />Pump Inspection By eery,..c. c Date ..} <br />PA - <br />COMMENTS 14.(2_119y4 Vi . PUT (-,/f,s1-2f0r771;1-: ----'. 1,7 <br /> <br />Soil Boring pipection By ,Cono structed Well Depth ti <br />PE <br />Codes <br /> • / <br />Sc <br />Into <br />Received <br />AD.-) <br />_,,..._,,,- <br />Cheat,/ <br />Cash/ , _, <br />, <br />Amount <br />Remitted <br />—1' <br />Permit/ <br />Service Request 0 Invoice It <br />---,...- . <br />Well 100 <br />'1364 17E /./ey-77kc.41- //67 ) <br />! Del <br />Ij17 Pi tit/P(4;4)414-0- <br />E00 <br />/2ST2Vs/2 :SS31:100V 31.1S Application Accepted By <br />DEPARTMENT USE ,ONLY <br />Date el/IP/Ai Area 4016 / Employee IDS <br />SPECIAL Well Permit <br />WAIVER Received