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WELL / PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3"FL-STOCKTON CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> ! tA �!J't CITYIZIP � G _! 'r,V �./�.3 � <br /> I <br /> JOB ADDRESS Q.�j ��./ <br /> CROSS STREET S f P.�Gl O'1 1 f�V -APN I S2 U "-/ PARCEL SIZE &I OfILLAND USE APPLIC(A�TIOON�# "(J�Vp(/r� <br /> /��,r/ 7 I PHONE '�`/ ✓ 3 ! �/ <br /> OWNER NAME / �� <br /> 1-A* u/�'''�` <br /> OWNERADDRESS �ju� ��. '�"r CITY/STATE/ZIP y•r� l�' "'"� r ��� <br /> CONTRACTOR /r' }1� e\. , A�i - J}PHONE/ 2�g 3[6�CONTRACTOR ADDRESS �Z/ / / ALJbLt-3I 1C.(rT[, LJt . CITYISTATE/ZIP <br /> r <br /> SUBCONTRACTOR PHONE <br /> f T <br /> SUBCONTRACTOR ADDRESS CITY/S �`]r/)Ztp <br /> L_ I L_ <br /> LICENSE C-57 ❑C-61 13D-09 ❑Other NUMBER 6- �/`_�_'-7 EXPIRATION DATE % /96rvlft7 <br /> GEOGRAPHICAL.INFORMATION. Coordinates X Y Towns ip y �lae�Y<piEE S�� Old <br /> INTENDED USE ❑Domestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Qua nkRIIJ Y L, A <br /> ❑Public Water System by_E4icRmbu.l ohWait�h Div7;y rnn <br /> If different fromOwner: Waler System Name <br /> TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification "Test Hole ❑Other <br /> Cl Monitoring Well(s) #of wells , ��p Soil Boring(s)__ #ofborings a orbor;nbs <br /> ❑Geotechnical <br /> ❑Well Destruction - ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal <br /> ❑New Pump ❑Pump Replacement ❑Pump Repair ❑Cross-Connection Repair <br /> WELL CONSTRUCTION <br /> Drilling Method ❑Mud Rotary ❑Air Rotary 'P11-ger ❑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 It <br /> I <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑Steel ❑Plastic ❑Stainless Steel ❑Other <br /> Grout Seal Depth ft ❑Neat Cement(941b hag/5-10 gal water) ❑Sand Cement .tack mix/7 gal water <br /> ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name 4,1K S ❑Specs on File ❑Specs Submitted <br /> Grout Placement Method ❑Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) <br /> t PEDESTAL Installed B ❑Driller ❑Pump Contractor ❑Other <br /> ❑Concrete Pedestal Dimensions: Width ft Length ft Thick in ❑Christy Box ❑Stove.Pipe <br /> PUMP ❑Submersible ❑Turbine ❑Other HP Pump Set ft 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 1S <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MINIM 24 HOUR ADVANC OTICE REQUIRED FOR INSPECTIONS <br /> SIGNED J TITLE .fyd DATE <br /> i PHASE II .� `m HAP $E --___S—°' _.. `-• +� L <br /> "e <br /> � 1 <br /> �.. I I fiTOMQ4e®1111OR10F 07ORWE;JILNN6'A' <br /> 11) <br /> � eropA�eelaa"o•a � � ' <br /> 4 ® sronwe unl.a„ae � e <br /> m <br /> — <br /> k <br /> P <br /> v. <br /> f � a�J� �C-►�'L.5 1f � <br /> SITE PLAN ' <br /> l <br /> k <br /> DE PARTM ENT USE ONLY <br /> . � .-.._,_ ,� ��_-� .'.=�-.�,`-�.,�r �' az. - ,-,•;ems -,�.��.:-=-,='---.--_ "---�.: ••....,a<.;�-'._ . :� .;� _,,..��_�__�_..��.� -�;•�.:42� <br /> r� <br /> Application Accented By -4 Date �d 5 Area Employee ID# <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection By i r' Date '❑ WAIVER Received <br /> Destruction Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#1 Amount Date Permit/ Invoice# Well ID# <br /> Codes Info By Cash Remitted Service Request# <br /> 4347- 150 �— o.o� : dp _L42s� <br /> EHD 43-02.006 WELL PUMP PERMIT <br /> H/6/04 <br />