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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 2009 953-7697 FOR INSPE NS EXPIRES/1 Y /�FROMM/t DATEISSUED <br /> JOB ADDRESS 7 1 1 IC - n l � t •z C n F�� m V N • (• ) m <br /> g <br /> CROSS STREET /A APN/673 Q PARCEL SigLAND USE APPLICATION# m <br /> VL , e y N <br /> OWNER NAME l�C / I {�� /y// PHONE �jt w <br /> OWNER ADDRESS / nnr K •/�-,. n CfY/STATEZP � 1i `�` <br /> Ctr4 C� V`/ +'L v PHDN <br /> CONTRACTOR /,� // 191 q /] <br /> CONTRACTOR ADDRESS UgI iA {L CITY/STA P S-h a C3 U <br /> SUBCONTRACTOR N l PHt/_O�/N/E <br /> SUBCONTRACTOR ADDRESS <br /> � IV I A CITY/STATErZV • • � VN <br /> LICENSE C-57 V G-61 D-09 Other NUMBER�l(bv EmPtATIon DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section_ <br /> INTENDED USE omestic/Private Irrigation/Agricultural Industrial Water Quality Monitoring Soil Sampling/Characterization <br /> Public Water System <br /> If different from Owner: Water bystern Name ami)or Phone Number <br /> TYPE OF WORK New Well Replacement Well Well Alteration/Modification Other <br /> MonitoringWell(s) of wells SoilBoring(s) #of borings Geotxhnlr�l #of borings (� <br /> Out-Of-Service W II Out-Of-Service Well Renewal Cross-Connection Repair <br /> New Pump <br /> um Pump Replacement Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <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 It <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Sched Steel Plastic Stainless Steel Other <br /> Grout Seal Depth ft Neat Cement(94 Ib bagl5-10 gal water) Sand Cement sack mix/7 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method Pumped Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller Pump Contractor Other <br /> Concrete Pedestal Dimensions:Width_It Length It Thick in Christy Box : Stove Pipe <br /> PUMP Submersible Turbine Other HP Pump Set I to It Standing Water Level ft JJ <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. f1 <br /> MINIM U 24 H !7R ICE NOTICE REQUIRED FO SPECT] 'IONpS-PLEASE CALL(209)y995 •7697 <br /> / <br /> SIGNED TITLE " 1 µ ljj 0 V1 DATEri <br /> ✓ Z Cl [�� <br /> v 1 <br /> N <br /> v� <br /> lie- <br /> �oo <br /> LsEIVED <br /> PAY MEN <br /> RECEIVED— G 29 2016 <br /> I I I lilt <br /> AUG 3 0 'MENTAL HEALTH <br /> JOAQun+ MIT/SEWCES <br /> VAE <br /> HFJE�1-TH DEPARTN <br /> PA TMENT UPE <br /> I/YAApplication Accepted Date (�'{ Area Employee IDiLQ S <br /> Grout Inspection By Date _.. SPECIAL Well Permit <br /> Pump Inspection By Date 1 I WAIVER Received <br /> Soil Boring Inspection By D to Constructed Well Depth ft <br /> COMMENTSri <br /> PE SC Received Chec Amount Data PeMW Invoice# Well ID# <br /> Codes Info B Remitted Service R uest# <br /> off" a gam/ ��� 7 3 2 <br /> EH07 1,06 WELL/PUMP PERMIT <br /> 4/3012 <br />