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I <br /> J WELL/PUMP PERMIT <br /> "fAi SOAj0jN COUN'T'Y ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3"FL-STOCKTON CA 95202-(209)46&3420 <br /> Aa� Cr <br /> NON-REFUNDABLE PERMIT— -AlALL 209 n'/ZIP 953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED n <br /> 1 F2r� �.�/' - <br /> Job ADDRESS / ( t 9 <br /> CROSS STREET APN -.?_f2-/C)0-423 PARCEL SIZE 22tAND USE APPUCATION# <br /> �/ L�7� <br /> I OWNERNAME ! P (�_ ( PHONE <br /> -Irl CCCL <br /> OWNER ADDRESS CITY/STATPJZIP <br /> vi/1Q'S�/ PHONE <br /> CONTRACTOR ... • � f l/ <br /> CONTRACTOR ADDRESS -� - C1TY(STATFJZIP J{'f��� C <br /> PHONE <br /> SUBCONTRACTOR <br /> SUBCONTRACTOR ADDRESS CrrY/STATE/ZIP <br /> LICENSE fid-57' ❑C61 1❑D-09- '❑Other NUMBER 'EXPIRATION DATE Zoe 7 <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y'• Township Range Section_ <br /> INTENDED Use M,,m Triv ue ❑,lrtigation/Agricultural Cl Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characteriation <br /> i ❑Public Water System CUjiiact ame or Phow Nuinkm <br /> IfdiHsram from Owner: W.Cf ystem SAM 1 .. <br /> i TYPE OF WORK f. w Well p(Replacement Well ❑Well Alteration/MOdification ❑Other <br /> s ofboringsp Gmtechnipl s of borings <br /> l ❑Monitoring WCII(s) #of wclls .Cl Soil Boring(s) <br /> ❑Out-Of--Service Well •r 131ut-Of-Service Well Renewal ❑Cross-Connection Repair t. o <br /> i ❑New P.wn . - ❑Pump Replacement -OPumultimair �y <br /> WELL CONS_rRVCTION <br /> h <br /> Drilling Method Mud Rotary�y�13 Air Rotary ❑Auger 12 Cable Tool ❑Push Point y�13 Other p <br /> Proposed Well Depth_,_-so .ft Excavation 1Z. in diameter ❑Open Bottom ia�'ravel Pack/Gravel Sim in diameter 1. <br /> ❑Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/GauWASTM Schell �lo ❑Steel'•�asnc 0 Stainless Stat. ;❑Otho <br /> Groat Seal Depth 9 ft ❑Neat Cement(94 lb bag/5-10 gal water) ❑Sand Cement sack mit/7 gal water <br /> �Belttonite(7201/.solids) ❑Manufacturer Spa 1/.solids_1/. Name ❑Spas on File ❑Specs Submitted <br /> ' Grout Placement Method ❑Fra Fall ❑Other ❑Retardant/Accelerator(name) 1� <br /> ` ftqKRAL installed By ❑Driller {Q92Irnp Contractor ❑ Other ft Thick in 13 Christy Box ❑Stove Pipe ll` <br /> ❑Concrete Pedestal Dimensions:Width ft Length <br /> PUMP ❑Submersible 13Turbine ❑Other' .HP Pump Set ft Standing Witte Level ft <br /> i 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 /> �CORRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS•STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> V WORKERS COMPENSATION LAWS L <br /> MINIMUM OUR ADVANCE NOTICE VQUIRED FOR INSPECTIONS �a-� <br /> SIGNED [/ !` /'[•�✓�� TITLE�i C I�4?r DATE J <br /> I <br /> 4 <br /> EP M <br /> J-11 4 <br /> 171 <br /> .. DEPAR.TME"NT USE ONLY <br /> f Application Accepted By ate Area Employee ID# U 4 <br /> Grout Inspection B ate 7 [3SPECIAL Well PerWit <br /> Pump Inspection By Dau " ❑ WAIVER Received <br /> Constructed Well Depth R <br /> COMME TS ® L-0 7-. eo <br /> PE Re <br /> SC ceived ec Amount PermiU <br /> Date Invoice# Well ID# <br /> Codes Info B ash Remitted Service R nest# <br /> 4agr(ffl -7 sAA) i o S oa5o v boa <br /> 1 <br /> WELL PUMP PERMIT <br /> EHD 430]-0(16 <br /> 11272005 __ <br />