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A WELUPUMP PERMIT <br /> - SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1 868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 <br /> NON-REF NDA LE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB AD E Z cL AA OV'"1 CITY21P CL � m <br /> } D <br /> CROSS STREET Nw LUt f\I'1C ' PNO�.�[J`�-N.]O' -3 PARCEL S¢E�.1-,t,LANDU APPLICATK)N# O <br /> //�� A <br /> OWNER NAME (�• f-1 E cV$[. /�D--?i�s�- -r^N, <br /> OWNER ADDRESS " �. -CrTY/STATE(ZIPLL`s/✓'RC,� <br /> CONTRACTOR l (� 741'- PHONE / , <br /> CONTRACTOR ADDRESS n /ICT CRY/STATE/ZIP Cs'^I '� ( /4 15 7 L <br /> fr <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITYIISSf�TATPJZIP !/ Z <br /> LICENSE ICC-57 C-61 0-09 Other NUMBER - LLl EXPIRATION DATE `/ ✓0 <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> F <br /> ENDED USE DomesticiPrivate Inigation/Agncultural Industrial Water Quality Monitoring X§od Sampling/Characterization <br /> Public Water System <br /> If dleerent from Owner Water System N.— Contact Name or Phone Number <br /> TYPE OF WORK New WBII Replacement Well Well AlteratiorvMGdification Other Q <br /> o • <br /> Monitoring Well(s) #of wells Soil Boring • f borings s) XGeotechnirai of borng, <br /> Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair LU Ott LL <br /> New Pump Pump Replacement Pump Repair Raise Well Casing O c <br /> WELL CONSTRUCTION > CV <br /> MINIMUM! CIE <br /> Drilling Method Mud Rotary Air Rotary )(Auger Cable Tool Push Point Other (V Z LL. <br /> cry <br /> Proposed 104 DepthI'S' It Excavation fv/J in diameter Open Bottom Gravel Pack/Gravel Size in diameter Uj N W <br /> Conductor Casing in diameter / Conductor Casing Depth It z <br /> WellCasing Diameter—in Thickness/Gauge/ASTM Schad Steel Plastic Stainless Steel Other ■ ■ Q <br /> Grout Seal Depth 15 ft Neat Cement(94 Ib bag/5 10 gal water) Sand Cement sack mix/7 gal water X a <br /> Bentonite(20%solids) Other ■1/ LU <br /> Grout Placement Method Pumped Free Fall Other Retardant/Accelerator(name) Yl• w <br /> PEDESTAL Installed By Driller Pump Contractor Other <br /> Concrete Pedestal Dimensions:Width 0 Length ft Thick in Christy Box Stove Pipe <br /> PUMP Submersible Turbine Other HP Pump Set It Standing Water Level ft <br /> 1 HEREBY CERTIFY THAT 1 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 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MINIMUM 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)/9537-7697�t^ A/0 <br /> SIGNED TITLE r �(Le! i'DATE ���A� <br /> 74 Z4 <br /> 2 <br /> T�Roiy��N�2o�g <br /> MF'vT <br /> 11 PA TMENTT USY <br /> Application Accepted By J Date- Area Employee ID#14� <br /> Grout Inspection By Date PECUIL WBII Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth K <br /> COMMENTS <br /> PE SC Received Check#1 Amount Date Permit/ Invoice# Well ID# <br /> Codes Info Cash s Itte a is o # <br /> 40 <br /> EHD43-06 revved40418 711-r3,7 -)�l_�{- WELL!PUMP PERMIT <br />