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X ' WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 EAST MAIN STREET-STOCKTON CA 95202 -(209)466.3420 <br /> NON-REFUNDABLE PERMIT 'CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> I <br /> �f� r <br /> JOB ADDRESS r 1V/� I CITYZP <br /> 1 �y 2 <br /> CROSS STREET w 7—,eCOdN /ct.� APN �.g—I7 -7S' PARCEL SIZE LAND USE APPLICATIONIlls <br /> #...777 <br /> OWNER NAME /I-�O PHONE C Xj/�� <br /> OWNER ADDRESS �'OI n J (5f�` CRYISTATE/ZIP �,e�/^ 4Y-��^�,A. <br /> CONTRACTOR WV r""�-' W PHONE (�.�1�/W/ �/—/f (/��/�c �j <br /> •� CONTRACTOR ADDREtU Ira 9-6 CITYISTATEIZIP�-�l/li� �7 I /'-ALJ <br /> 's <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CRY/STATEIZIP <br /> LICENSE 57 11C-61 00-09 0 Other NUMBE�3� /f EXPIRATION DATE X L2 / <br /> GEOGRAPHICAL INFO ATION: Coordinates X Y Township_ Range Section_ <br /> INTENDED USE estic/Private ❑Ir igatlon/Agricultural 0 Industrial 0 Water Quality Monitoring 0 Soil Sampling/Characterization <br /> 0 Public Water System <br /> .. If different horn Owner: water 5y"m Nam uontact Name or Phone Nurnber <br /> TYPE OF WORK New Well 0 Replacement Well 0 Well Alteratlon/Modification 0 Other <br /> ❑Monitoring Well(S) #Of wells 0 Soil Boring(s) •of borings 0 Geotechnical 01 of borings <br /> 0 Out-0f-Service Well :]Out-Of-Service Well Renewal 0 Cross-Connection Repair <br /> 0 New Pump 0 Pump Replacement 0 Pump Repair 0 Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Vll l.d 0 'r Rotary U Auger 0 Cable Tool ❑Push Point Other <br /> Proposed Well Dep �— Excavation 10 In diameter ❑Open Bottom 0 Gravel Pack/Gravel Size in diameter pp� <br /> 0 C duct g in diameter / Conductor Casing Depth ft W <br /> Well Casing Diameter In hldmess/Gauge/ASTM Sched 2JX 0 Steel FSPlastic ❑Stainless Steel 0 Other <br /> Grout SealDe`pth . ❑Neat Cement(94/b bag/5-10 gal water) 0 Sand Cement sack m1x/7 gal water <br /> Nth <br /> (20° lids) 0 Other <br /> Grout Placement Meth umped O Free Fall 0 Other ❑Retardant/Accelerator(name) <br /> I[I PEDESTAL Installed By 0 Driller ump Contractor ❑ Other <br /> 0 Concrete Pedestal Dimensions:Width ft Length ft Thick In ❑Christy Box ❑Stowe PlpeyJA <br /> PUMP 0 Submerslble0 Turbine 0 Other HP Pump Set ft Standing Water Level ft (1 <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN Ilt` <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 /> M=12 IOU_ DVANCE NOTICE REQUIRED FOR IN ECTIqbIS PLEASE CALL(209)95 -7 97 Z <br /> SIGNED TITLE <br /> DATE <br /> TTT <br /> r <br /> A <br /> F <br /> ;. <br /> r <br /> FD F.p..A R.ZM_E TSU-S E O N L_Y <br /> Application Accepted By Date CO Area Employee ID# <br /> it Grout Inspection By ate D ❑ SPECUkL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspechon By Date structed Well D th ft <br /> COMMENTS LOO u-- S/ ,is F[.00 O <br /> i <br /> P£ Sc Received Amount Date Permit/ <br /> Codes Info B Cash Remitted Service Request# Invoice# Well IDS <br /> '34.6 r ko SS 19 :?LII yl alaz �v o03 (6 <br /> 1 <br /> EHD 4106 <br /> 6116109 WELL!PUMP PERMIT <br />