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WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468.3420 <br />NON-REFUNDABLE PERMIT CALL (209) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />ti <br />JOB ADDRESS C/�,�1 /, �.2 DL Cm21P se A10'3 �) L - <br />CROSS STREET l� K 1�1��1 �' Yl4 ('ii�N ��/ / l v!T PARCEL SIZE 1 i LAND USE APPLICATION #L/ ..// <br />OWNER NAME - n PHONE <br />OWNER ADDRESS CRY/STATE/ZIP <br />CONTRACTOR PHONE <br />CONTRACTOR ADDRESS 7 CRYISTATEIZIP /,YP - <br />SUBCONTRACTOR PHONE <br />ADDRESS <br />CITY/STATE/ZIP <br />LICENSE C-57 4f -C-61 D-09 ' Other NUMBER EXPIRATION <br />GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br />INTENDED USE Domestic/Private Irrigation/Agricultural Industrial Water Quality Monitoring Soil Sampling/Characterization <br />Public Water System <br />If different from Owner. r SyStOM Name contact ameorPhone Number <br />TYPE OF WORK New Well- Replacement Well D Well Alteration/Modification Other <br />Monitoring Well(s) # of wells C Soil Boring(s) A of borings Geotechnical it of bonngs <br />Out -Of -Service Well Out -Of -Service Well Renewal Gross -Connection Repair <br />Drilling Method Mud Rotary Air Rotary Auger Cable Tool Push Point Other <br />Proposed Well Depth ft Excavation in diameter Open Bottom - Gravel Pack/Gravel Size in diameter <br />Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Schad .. Steel Plastic Stainless Steel ' Other <br />Grout Seal Depth ft Neat Cement (941b bagiSlO gal water) Sand Cement sack mix/7 gal water <br />Bentonite (20% solids) Other <br />Grout Placement Method Pumped Free Fall I Other Retardant / Accelerator (name) <br />PEDESTAL Installed By -. Driller ' Pump Contractor - Other <br />Concrete Pedestal -Dimensions: Width ft Length ft Thick in Christy Box Stove Pipe <br />PUMP ubmersible Turbine - Other HP 1 Pump Setft 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 />NOTICE REQUIRED FOR//INSPECTIONS - PLEASE CALL (209) 95? -7997 <br />e <br />TITLE ,, / DATE S •w� <br />�F SMF <br />CFjV �I' <br />iCn _ <br />)q � Q ?o?? <br />QUI <br />'OE CO <br />�NTy <br />MFNT <br />DEPARTMENT USE ONLY j <br />Application Accepted By �� Date I +i' Area tl%Employee ID# <br />Grout Inspection By Date F]SPECIAL Well Permit <br />Pump Inspection By Date 11 WAIVER Received <br />Soil Boring Inspection By ' Date Constructed Well Depth ft <br />COMMENTS / � E?L/ ./ 4 e J". Ii�� P - ) J Vy � it l ' L4,? \- <br />PE SC Received eCheqW <br />Info B <br />Amount Date <br />Remitted <br />Permit/ Invoice # Well ID# <br />Service Re Set III <br />�CJodess <br />EMD 43-M WELL /PUMP PERMIT <br />41=12 <br />