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WELUPUMP PERMIT <br />SAN JOAQUIN COUNTY ENNRONYENTAL HEALTH DEPART4ENT 1868 EAST HAZIELTON AVMX - STOCKTON CA 95205 - (209) 4683420 <br />NON-REFUNDABLE PERMIT <br />CALL 209 953-7697 FOR 1 <br />PECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />OO <br />Joe ARESS <br />s <br />u e e <br />tjr s <br />- S (U <br />32T <br />CROs STREET <br />APN <br />— -O <br />ARGEL S. ` [ LAM US AAPLICATION # <br />OWNER NAME <br />` <br />a <br />rZ <br />OWNER ADDRESS <br />(; <br />CP <br />72 r/,, <br />lzc <br />T <br />U <br />CONTRACTOR <br />L Ot v <br />IIW <br />CPHONIE <br />v <br />O <br />CONTRACTOR ADDRESS <br />L � •� <br />C1WST1 <br />IV <br />'SUBCONTRACTOR <br />P <br />I SUBCONTRACTOR ADDRESSS/�—'—I '— <br />(LICENSE C-57 C61 D -QS <br />'INTENDED USE <br />i <br />Coordinates X Y <br />(�j( �1nSTATeI2,s+ 1 V ► ►-1 <br />1rtAteat ' `� � `� E>r>ntATaN DAre t <br />Township_ Range section_ <br />uomesuvrmra[e In gavoruAgriculturai Industrial Water Quality MOrilonng Soil Sampling/Characterization <br />Public W .ter System <br />If dUleera firm Umar rtte <br />TYPE OF WORK New Well Replacement Well Well Atteration/Modlfication Other <br />Monitoring Well(s) _ #Of welts SOd Borin7(s) OMUarinpa - ti0O1a "�'rir�l a°rsxfna. <br />uvea Out-OISeniice Well Renewal Cross -Connection Repair <br />Pump ;Replacement Punto Repair Raise Well Casing <br />Drilling Method Mud Rotary Air Rotary Auger Cable Tool Push Point Other <br />Proposed Well DepU R Excavation in diameter Open Bottom Gravel PaddiSkavel Size in diameter <br />Conductor Casing in diameter / Conductor Cesing Depth R <br />Well Casing Diameter _ in ThidOtess/GauglWASTM Schell Steel Plastic Stainless Steel other <br />Grout Seal Depth ft Neat Cement (941b ba915-10 go/ water) Send Cement sack mbd7 gal water <br />Bentonite (20% solids) Other <br />Grout Placement Method Pumped Free Fag Other Retardant / Accelerator (name) <br />PEDESTAL Installed By Driller Pump C itractor Other <br />Concrete Pedestal Dimensions: Width it Length R Thiry in r!hriery P. c...... D4— <br />PUNA V Submersible Turbine Other HP ­J2�_ Pump Set I �JV R Standing Water Level ft <br />I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK VAI -L BE DOME IN ACCORDANCE WITH SAN <br />IOAQUIN COUNTY ORDINANCES, STATE LAWS. AND RULES AND REGULATIONS- I ALSO CERTIFY THAT MY REQUNED LICENSE IS <br />CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM W COMPLIANCE WITH ALL <br />WORKERS COMPENSATION LAWS- I <br />MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOPJQNSSPECTIOn NS - PLEASE CALL (209) 953-769]7 <br />!/" � <br />SIGNED TITLE V ( li rfI �j V1 DATE r ,/ <br />P t1► <br />APplicaoon Accepted By <br />Grout;nspedion By <br />Pump Inspection By <br />Soil Boning Inspection By <br />COMMENTS.. <br />TMENT U E NLY <br />---Gate 71-7 <br />Date <br />Date r' I <br />Date <br />T <br />N <br />t� <br />��LO <br />MAY 1 1 2017 <br />VINOAIi'14ENTAL HEALM <br />PERMIT/-Er�V! FS <br />\i�ll7Aq <br />!l�19■■����� <br />II_;t�i�l�liv■■■■■■■ <br />LIMOM■■■■■■■■■■■ <br />■■■■■■■■■■■■aSAA, j0,4te <br />■■Area Employee ID# <br />SPE&AL Well Permit <br />1�■s■■■■■����t�►■ <br />r <br />DepthWAIVER Received <br />Cons1ruclied YM <br />EN- :>JE <br />a0012 W81 RUW PERMIT <br />