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WELLIPUMP PERMIT <br /> SAN JoArWN CcuNrr EPmRohatexTAL HEALTH DEPARTntem 1866 EAST HA2aLT0N AveNuE•STOCKTON CA 95205•(209)464J420 <br /> NON-REFUNOABLE PERMIT _ CALL 1209)953-7697 FOR INSPECTIONS EXPIRES 7 YEAR FROM DATE ISSUED <br /> .los ADGRESa SAO i Wcat Linc CrTYMP StOCktort.CA 95210 1 <br /> CRoas STREL-E Morrda Lane ApN — U 'Q <br /> ARGEL StiE 4.83 LAAIO U3E ArPUGTON A <br /> OWNER NAME City of Stockton Public Works Department-Contact.Antonio Tovar P,om 209 937.7390 <br /> w <br /> OWNER ACORESs 22 E.Weber Avenue,Room 301 crrwSrATY11r Stockton,CA 95202 <br /> CONTRACTOR V&W DI-Nznj,:nc -Contact:Kali Stroirf pil Cell:209.981.7755 <br /> COWMCTOR ADDRESS 33 Blackhurst Drive CmlBrATVLr Gall CA 95632 <br /> SUBCOMRAr-OR Pmwa <br /> !SUBCONTRACTOR A::R6S0CA <br /> CITY/STATEZP <br /> 'LICENSE X C-57, C-51 0 D-02 C Omer NumaER 720904 EkpRATON DATL 04/3D17020 <br /> DWmEsrc W2....SAmpuno:=General Mineral/CIO!itorm Bacteria(4391) DibrOmoCriloropropane(4392)'�Arsenic(43931 <br /> �WOEO Use 0 00MUSCIPAvate 0 1fTlgaaorJAgnG.Grura; 0 Industria! -Wafer puaGty.Monitonnp C Soy Sart>p+inprCnaracterixatwr .o <br /> 0 Public Water System �^ <br /> If NIweM tem Amer tv", em i- enact Nrrr a one NwrAer O <br /> TyetOF WORK D New woo J Replacement Wall C Well AI»ratonIM0*11caaon D ONtr___ _ <br /> C MonhOnng Wmrtl(s1 So,webs C Shc 8onng(s) '°r0 mp X Gtoteulnical 4 a^rb-Mw <br /> C Out-Of-Sarwce Wt:; C 014-0fSONCt Ws:;Rermawa; '7 CrowConnecton Repar <br /> D New FunV C P6=Raflacement 0 Pu:-c er 0 Raise Well Cast <br /> W11"CONS R hT.O b <br /> Drilling Method C H-ld Rctary C Air Rctary X Auger D Cable Tooi _Push Pont - Otner <br /> Proposed Welt Deaf. 25 !t Excavaton 4 12 lr.diameter L Open BettcM i,G.-ava.P&OVGrmvC See In d-36— <br /> A <br /> em C <br /> CordJdor Casing In diameter r Ccnductor ,Casae DepP._ft O I <br /> Wa,:Casing ,nianaiar_In TWCluT4wGaupa/ASTM Shed C Steel Z P:asrc C Staikess Steel C Otte- L/d� <br /> Grout Seal Depth full depth ft X Naat Cement(ce IC o1yS70 par caster, Sane Cement tai k,�7,oai water 3 n <br /> C Btntonhe(201ti solids; D Ot`er ,� O�U <br /> Grout Placement Method Purnpad C Free Fat; ',^t1 =Rata dsr t'Accelerator(name C <br /> P TA !nsatlad By 0 Driller 0 Pump Contaacr = Outer F,t o(J/yn <br /> Concrete Pedrsm 00imenslons:Wild' R Len"_ft R TNCk to ^Christy Box C Stove Pipe <br /> Puwv D SuorrersiDtao T rtNne C OL,.er HF PJmp Set ft Standing Watar LevC R MFNr <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 THAT MY RFCUREO LICENSE IS <br /> CURRENT AND AC WTTH THE CALIFORNIA CONTRACTORS STATE UCENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COM ON LAWS. <br /> MINIM !-18H V NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIONtO Tau Vicc Presidcm EnRineenrw Services DATE 1211 L18 <br /> I l <br /> I <br /> 1 j <br /> I <br /> ! <br /> i <br /> I <br /> r , <br /> I I <br /> 1 <br /> P A T M E N T US O L w <br /> Appficaton Accepted By r to � Area Emxoyes toe <br /> Grout Inspection ByDate _ Al..Well Permit <br /> Pump Inspection By Cate_ WAIVER Received <br /> Sou Bonne inspeaon BY Date Constructed well Depth <br /> COMMENTS <br /> PE C Recawed -- Amount Date Perm,t' Invoices Wellll)ts <br /> Codes Info Cash emt d Service Re :nstB <br /> ly <br /> i 1 <br /> I ' <br /> i <br /> ENJ aye;aMp 4't U;i <br /> WEt�A SMP rERM^ <br />