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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZFLTON AVENUE-STOCKTON CA 95205-(209)468-3420 <br /> NON-REFUNDABL P RM T CALL f2091 953-7697-ORI SPECTIONS PIRES 1 Y FROM DATE ISSUED <br /> LP 0 VV rAuN <br /> .JO9 ADDRESS GTYIZIP C- <br /> q �/� 2�- D <br /> GROSS STREET I � Q- P ✓ PARCEL SIZE �) +� LAND USE <br /> C�I-N A <br /> 5 t� ` m <br /> OWNER NAME ) PHONE l� w <br /> OWNER ADDRESSO(p l.t CITY(STATE21P <br /> PH NE �� <br /> _CONTRACTOR 'A 1 /A (� <br /> CONTRACTOR ADORE 5 "'" tr CITY/STATEff v/` <br /> dMfD <br /> SUBCONTRACTOR / 1 -�/tI P/HO(YI7—I}�� <br /> SUBCONTRACTOR ADDRESS ry / ` �TATErLIP f , f <br /> I/Y_(llVVn <br /> LICENSE $7 C-61 D-09 Other_ NUMBER EXPIRAT ON DA E <br /> DOMESTIC WELL S9tPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE V D0meStIC/PHv8te Irrigation/Agricultarat Industrial Water Quality Monitoring Soil Sampling/Characterization <br /> Public Water System <br /> if l terem fro,0--er Nater System Name contact Name or Phone Number <br /> TYPE OF WORK New Well Replacement Well Well Alteration,Moeifcaton Other <br /> s <br /> Monitoring 4Vell(sj X of wells Soil Borirgtsl tt of bonn S Geotechnical #of borings r� <br /> OuT-Of-Sen,ice 11 Out-Of-Serr,ce V"all Renewal Cross-Connection Repair <br /> New?um Pum Replacement Pum Reps r Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary Air Rota uger Caole Tool Push Point Other <br /> Proposed Well Depth h Excavation in diac.eter Open Bottom Gravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_;n. Thickness/Gauge/ASTM Sched Steel Plastic Stainless Steel Other <br /> Grout Seal Depth ft Neat Cement(94/b bag15-10 gal water) Sand Cement sack mix.7 gal water <br /> Bentonite(20%solids) Other C <br /> Grout Placement Method Pumped Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Ins alled By Driller Pump Contractor Other <br /> oncrete Pedestal Dimensions:Width ft Length ft Thick in Christy Box St ve Pipe <br /> PUMP Submersible Turbine Other HP Pump Set_LV U 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. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS yJ <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WOR d64PENSATION LPfVS. <br /> MI UM 24 H LOR WA E NOTICE REQUIRED FO 'INSPECTIONSPLEASE CALL(209) 97 C <br /> SIGNED 147, <br /> ITLE `-'I ✓ 1 lam( !I 1�A Y,1� DATE <br /> I i <br /> — I i <br /> P4 Y41, <br /> JI i 171 <br /> gl jG �® <br /> I � 0 <br /> 5 <br /> joA ?019 <br /> V/ <br /> j I TyR0, OUN <br /> of o NT ry <br /> E ARTMENT E ONLY <br /> Appitaatlon Accepted By Cate �l.S�t2��/ Area Employee ID# - <br /> CrOLt Inspection By IZ Date SPECIAL Well Permit <br /> Pump inspection By 4djl;" Date U I k211)Dn WAIVER Received <br /> Sod Boring Inspection By A A n Date Constructed Well Depth ft <br /> / <br /> ..7M1.IMENTS _�_ _ r AAz _ <br /> �vl/vy <br /> PE SC Received Checkdt Amount pate PermN Invoice# Well ID# <br /> Codes Info B s Remitted Service Request# <br /> I <br />