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WELL / PUMP PERMIT <br /> SAN JOAQUIN COUNTI'ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER Avi,3""FI.-STOCKTON CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED N <br /> / �. G' � ren <br /> JOB ADDRESS <br /> �J^3y lr�Ns i.G'o-�t Crry/LIP ��'"1/ / 7J �'G y <br /> f v <br /> /yam0 <br /> APN O—�7 PAI:CEI,SI'/,F: <br /> CROSS STREET <br /> OWNER NAME S/2 /' ,��R ! PHONE <br /> y S 5 <br /> OWNER ADDRESS Tl-� CITY/STATE/LIP ^ 5'1 S 6� <br /> O ��� <br /> i <br /> ` PIIONE <br /> CONTRACTOR {^ <br /> CONTRACTOR ADDRESS <br /> PHONE! f 9 <br /> S W <br /> SUBCONTRACTOR ADDRESS CITY/STATE/LIP , <br /> LICENSE ❑C-57 ❑C-61 ❑D-09 ❑Other NUMBER 6621.23-LL EXPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section 1 <br /> INTENDED USEDomestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization <br /> ❑Public Water System Contact Name or one Number <br /> If di((erent from Owner: Water System Name <br /> TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification ❑Test Hole ❑Othcr .E hA ,4e. <br /> number of borings number of boring' <br /> C3 Monitoring Well(S) <br /> number of wells ❑Soil Boring(s) ❑Geotechnical <br /> ❑Well Destruction ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal (� <br /> ❑New Pun12 ❑Pum2 Re lacement ❑Pump Repair ❑Cross-Connection Repair <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 ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑Steel ❑Plastic ❑Stainless Steel ❑Other <br /> Grout Seal Depth ft ❑Neat Cement(94/h hug/5-/0 gal water) ❑Sand Cement suck mix/7 gal water <br /> ❑Bentonite(20%solids) ❑Manufacturer Spec%solids_% Name ❑Specs on File ❑Specs Submitted <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 III Thick in ❑Christy Box ❑Stove Pipe <br /> PUMP ❑Submersible ❑Turbine ❑Other lip <br /> Pump Set Il Standing Waler Level It <br /> WELL DESTRUCTION 0 Open Bottom ❑Gravel Pack ❑Uncased ❑Other <br /> Well Diameter in Total Depth II Depth to Water fl ❑Casing to be Perforated Gom it to tt <br /> Sealing Material ❑Neat Cement(94/h hug/5-/0 ga!water) ❑Sand Cement sack mix/7 gal water ❑Bentonite Pellets <br /> ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted <br /> Placement Method ❑Pumped ❑Free Fall ❑Other <br /> ❑Complete with Mushroom Cap ft below grade ❑Complete to Existing Surface Pad <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. 1 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 LAW <br /> MINI ✓ 24 VANCE NOTICE REQUIRED FOR INSPECTIONS— PLEASE CALL(209)953-7697 <br /> SIGNED TITLE D /C� i�/°T� ]'�- DATE <br /> D <br /> Ul v <br /> 5 N O �i SU A" <br /> r)t1 <br /> ILEI 14 t <br /> DEPARTMENT <br /> /USE ONLY �7 q37 / �� <br /> Application Accepted By (`J�_ U Date !/(lz� ���� Arca Employee mployee ID# '7� p� <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection B Date a� ❑ WAIVER Received <br /> Destruction Inspection By Date_ Constructed WelLooDeptit_ ft <br /> N <br /> COMMENT'S <br /> PE SC Received heck# Amount Date Pe it/ Invoice# Well ID# <br /> Codes Info 1; ash Remitted Service Rc uest# <br /> 3�'O D.S'v -7 35?' -0 - 1 ID3 - <br />