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6ECE "N Wd00 :E 0 [06 '6l 'unr 9WIJ paAI ;O;d b <br /> WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAWLTON AVENUE-STOCKTON CA 45205 -(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED <br /> JOBADDR/E^� ;. , i''�+,� Cox Rd cl-rrjzp Linden Ca 95236 <br /> CROSS S77lEET /!1 -�'�/�[.�� APN i �PARCFI SIZE .. C O USE APPUCATK)H# p <br /> A <br /> OWNER NAME Marciano Ranch PRoN209-403-4275 H <br /> OWNER ADDRESS 6 7,(�..�_N Cox Rd aTw sTA,E/aPL i n d e n C a 9 5 2 3 6 <br /> CONTRACTOR Pu-r viance Drillers , Inc PHONE 209-887-3554 <br /> CONTRACTOR Amoimss 'PC) Bo x 64 CITY/STATFrdPL i n d e n C A 95236 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITYIS'rATE/7JP <br /> LlcatsE X Csr D Ge,, a D-09 0 Other NuNam 377923 ExPIRATON DATE 7/31/19 <br /> DOmEsTTc WELLSAMPUNG:D General Mineral/Celiform Bacteria(4391)L Dibromochicropropane(4392):]Arsenic(4393) <br /> INTEVDED USE 16 DomeSkPnvate C IrdgationlAgricutural G Industrial C Water Quality Monitoring O Soil Sampling/Charactetizaton <br /> C Public Water System <br /> 'fdiRemr,fmm Owner Watersystem Name Comae Nene or Phone Number <br /> TYPE OF WORK U NeW Well 0 Replacement Well C Wel.AlierationlModification 0 Other <br /> 0 MonitoringWell(s) #ofviells C SalRoring(s) sofbodngs G Geotechnical eOfborw; [> <br /> 0 Out-Of-Service Well C Oul-OfService Well Renewal U CrossLonnection Repair PAY <br /> 41 <br /> New Pum PurnRe laoement 0 Pum Repair C Raise WPI Ca 4n ���� <br /> WELL CONSTRUCTION <br /> Drilling Method n Mud Rotary F.Air Rotary O Auger L Cable Tool n Push Point D Other / A <br /> Proposed Well Depth ft EzwvatIon in diameter 0 Open Bottom ti Gravel Pack/Gravel Size in diamel'2 <br /> 7 ft N <br /> Conductor Casing in diameter f Conductor Casing Depth <br /> Well Casing Diamatre,____in Thickness/GaugeJASTM Schad 0 Steel ❑Plastic C Stainless Stod 1:1 Other <br /> SAN �O�OD <br /> Grout Seal Depth fl 0 Neal Cement(94/b bay6.10 gal water) 0 Sand Cement sack--17NT' FNM COU' <br /> V7 <br /> Bentonite(2D%solids) .0 Other C��9 Fp �MEN�y <br /> Grout Placement Mettwd L Pumped D Free Fall Other 0 Retardant/Accelerator(name) A/�T <br /> D <br /> PEDESTAL Installed By 0 Driller C Pump Contactor 7 Other <br /> L Concrete Pedestal nDimenslong:Width ft Lengt'I ft Thick in I-,Christy Box O Stove Plpe <br /> P17MP 41 SubmersiblefT Turbine G Other Hp---!:71— Pump Sal ft Standing Water Level ��F( <br /> 1 <br /> 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 SHAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WO PENSATION LAwS. <br /> MINI M VANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED GG -c- TITh o r p o r a t e S e c r e t a r ti, /. <br /> I <br /> 14 <br /> I ' <br /> I <br /> i I I <br /> I I <br /> EP R T M E N T U 1^ -!��(--`- <br /> Application Accepted By Cale !�✓ Area Employee IDA/&/0K/(q <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection By Cate ❑ WAIVER Received <br /> Soil Boring Inspection By Dace Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#/ Amount Date Permly Invoicett We111IIq <br /> Codes Info h Remitted 'c Re uesttl <br /> FHn43,A M1lfaWELL/PUMPPERLUT <br /> 7�g��69I <br /> Z•d out saelp)Q eouel and d0V:70 2 L 6 L ung <br />