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S <br /> WELUPUMP PERMIT <br /> SAN JOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> rn <br /> JOB ADDRESS 1 17 L ��� P 1�� <br /> CITY/ZIP �� C _�(S1�- L� D <br /> CROSS STREET_t a 1,i ky—,, t -A APN,�U)"-D��U -25 PARCEL SIZE �' LAND USE APPLICATION# m <br /> n <br /> OWNER NAME t�C,�1L(C PHONE Zm� `)J LIL <br /> OWNER ADDRESS 1) 1� ~. V1 c.,, 1l� CITY/STATE/ZIP E '(ti 1 COY, l'((', <br /> CONTRACTOR W e1 T �` T�x �i \ ' '( (A� 1 bv-. PHONE c 2�,2) 1 5 `> 7 5 `1 1 <br /> CONTRACTOR ADDRESS , Gc ' 7 CITY/STATE/ZIP5 C <br /> SUBCONTRACTOR _ PHONE(zo �I 9 '� _I 11�%I <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE C•57 C-61 D-09 Other NUMBER 7 0 I EXPIRATION DATE I ( I �� <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE ,d Domestic/Private t. Irrigation/Agricultural i.l Industrial ,:1 Water Quality Monitoring U Soil Sampling/Characterizat'LQD <br /> I I Public Water System <br /> If different from Owner: aterystem ame ro­nIac-1 Name c�r—F-h­one Number MrAz <br /> it­ <br /> TYPE OF WORK ❑ New Well y'Replacement Well E Well Alteration/Modification I i Other <br /> ❑ Monitoring Well(s) #of wells - Soil Boring(s) a of borings Geotechnical # heo <br /> ❑ Out-Of-Service Well DOut-Of-Service Well Renewal 1_1 Cross-Connection Repair +SAIVJ �®1� <br /> F11NewPum Pum Replacement CPum Repair 11 Raise Well CasingFri/V qQU/N <br /> WELL CONSTRUCTION Ty pEp-F�TAC <br /> Drilling Method XMud Rotary I Air Rotary i Auger Li Cable Tool 1 Push Point F1 Other <br /> Proposed Well Depth � r <br /> ft Excavation I c 1 <br /> y in diameter Open Bottom 1 Gravel Pack/Graval Size / in diametcr <br /> Cunducior Casing in diameter / Conductor Casing Depth _ It <br /> Well Casing Diameter_(;L in Thickness,'Gauge/ASTM Sched -�-h I)___ _1 Steel -V Plastic -i Stainless Steel D Other <br /> Grout Seal Depth ft F. Neat Cement(94 le bag/5--10 gal water) 'Sand Cemen_i� W sack mix/7 gal water <br /> I I Bentonite(20%solids) I 1 Other (�✓� < ^l tt ,'7 r,"� �" R 0-0 �1` <br /> Grout Placement Method ✓Pumped _1 Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By �1 Driller ;!Pump Contractor a Other <br /> Concrete Pedestal Dimensions:Width ft Length ft Thick in 1 Christy Box r Stove Pipe <br /> PUMP Submersible1 Turbine I! Other HP Pump Set It 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 LAWS. <br /> MINIMUM 24 HOUR A /ANeE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br /> SIGNED TITLE_ � �� DATE L�S <br /> I <br /> 1 <br /> I <br /> DEPARTMENT USE NLY <br /> Application Accepted By �� J ` — Date 211-CII Area Employee <br /> Grout Inspection By Date I SPECIAL Well Permit <br /> Pump Inspection By 1-7 Date 11 WAIVER Received <br /> Soil Boring Inspecdion By Olite Constructed Well Depth _ ft <br /> %MMENTS � tjfJ i�hc - T- t+ C L c:c SC Received hem Amount PermiUInfo B - Remitted Date Service Re uest# Invoice# Well ID# <br /> 2 <br /> EHD 43-06 WELL/PUMP PERMIT <br /> 4/30/12 <br />