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WELL / PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH&►<RTMENT 304 E WEBEW1 A 340 FL-STOCKTON CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> n // <br /> �f `` L 9s-�yoC m <br /> JOB ADDRESS i�iyo> �• ��`���•^��/r •C(J� CITY/ZIP > <br /> ++ ('!:Y <br /> 0 <br /> CROSS STREET E Cl /211. APN O SS" /.,ZV - C"/ PARCEL SIZE GLAND USE APPLICATION# <br /> nrH7.� <br /> OWNER NAME PHONE <br /> OWNER ADDRESS 1 t CITY/STATE/ZIP <br /> CONTRACTOR k•/r.:?• ej r 1.,t. PHONE (222) <br /> CONTRACTOR ADDRESSM�ir7le S'7' CITY/STATE/ZIP -J/O<""/fTA^l <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE E C-57 ❑C-61 ❑D-09 ❑Other NUMBER el(57&R EXPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township _ Rang! Section _ <br /> INTENDED USE ❑Domestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring Soil Sampling/Characterization <br /> ❑Public Water System <br /> Ifdlfferent Dom Owmm: Water systern Na= Conmct Narre or Phom Number <br /> TYPE OF WORK ❑New Well ❑Replacement Well 13❑Well Alteration/Modification <br /> **M <br /> Other <br /> ❑Monitoring Well(s) #of wells M Soil Boring(s) 5 #ofbonnga ❑Geotechnical v of tadngs <br /> ❑Out-Of--Service Well ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> ❑New Pump ❑Pump Replacement ❑PumpRepair <br /> WELL CONSTRUCTION <br /> Drilling Method ❑Mud Rotary ❑Air Rotary \V Auger y ❑Cable Tool ❑Push Point ❑Other f1��Vlj <br /> Proposed Well Depth 0 5 ft Excavation `7/ .2 in diameter [I 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 Sched [3 Steel 13 Plastic ❑Stainless Steel ❑Other <br /> Grout Seal Depth ft Neat Cement(94/h bag/5-Pogo!wafer) ❑Sand Cement sock mix/7 gal water �7 <br /> ❑Bentonite(200/6 solids) ❑Manufacturer Spec%solids % Name Tr-r -" " /'F'+• ❑Specs on File ❑Specs Submitted f3•�. <br /> Grout Placement Method ❑Pumped ❑Free Fall ❑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 ❑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 IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION WS. <br /> INI UM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> SIGNED J'— TITLE —MCA' DATE �4/ &7 <br /> MEN1] <br /> MEN <br /> MEN OEM! <br /> NON ONE <br /> MEN <br /> MEN <br /> ^.1 <br /> MEN 4 <br /> MEN MEN <br /> MEN <br /> MEN <br /> SEMI <br /> MEN <br /> MEN NON <br /> MEN ME <br /> MEN <br /> ME <br /> MEN <br /> MEN INN <br /> EME <br /> \\V <br /> 1 <br /> © SEE <br /> won <br /> couNi <br /> a; e r rrc <br /> Arnn� � <br /> PARTMENT U E OAA 'LjY qC, <br /> Application Accepted By Date J R / Area Employee lD# 5 / Y �/O[ <br /> 6i inspection By i Date G ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Constructed Well Depth �/ nn , ft ! 1 � <br /> COMMENTS � .rn/�.a_ 1!_ UJ/ .��GL / %//✓ t. Cf2:b✓Z�.�cJ Ge� �jl�i.+/!?NYG {jQgn),� <br /> PE SC Received c heck#/ Amount PermiU <br /> Codes Info B as Remitted, Dale Service Re uest# Invoice# Well ID# <br /> 1303 3- 3 0 <br /> EHD 0-02-006 WELL PUMP PERMIT <br /> IR7/2005 <br />