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t <br /> WI -UPUM!' PERMIT <br /> SAN JOAQUIN COUNTY ENvrRONr.1ENTAL I'iEALTH DEPARTMENT 18GB EAST IIAZELTON AVENUE-STOCKTO14 CA 05205-(209)4GB-5420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS NIP <br /> CITY/ZIPo <br /> m <br /> CROSS STREET r��./JIyA{/Y�/p'r/�t.- {--APN 4� ~`� V--�_NARCEL SIZE LAND USE APPLICATION# <br /> OWNER NAME �C��—/—/�- -�.���! PHONE <br /> �/,y�/ <br /> OWNER ADDRESS 6y — CITYISTATE/ZIP 5^""""")" <br /> CONTRACTOR L �/ �f PHONE 2,`m/ [�1't V 1'7 T-/C/`�7 Z- <br /> CONTRACTORADDRESS / lir 1. 11 ` CITY/STATE/ZIP_/ N//06 /�(_ _ <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATEIZIP <br /> LICENSE U C-57 C-61 a D-09 ii Othef NUMBER({) )� _ EXPIRATION DATE `l ✓v <br /> DorAESTIG WELL SAMPLING:I7 General Mineral/Coliform Bacteria(4391)u Dibromochloropropane(4392)t7 Arsenic(4393) <br /> INTENDED Use Domestic/Private U Irrigation/Agricultural IT Industrial Water Quality Monitoring II Soil Sampling/Characlerization <br /> D Public Water System <br /> If different horn O,ner: Wale'System Name Contact Name or Phone Number <br /> TYPE OF WORK D New Well -1 Replacement Well ❑Well AlteralionRvtodificatlon 0 Other <br /> ❑Monitoring Wells) #of wells Il Soil Boring(s) n of bminas I 1 Geolechnical #m borings <br /> I I Out-Df-Service Well n Out-Of-Service Well Renewal O Cross-Connection Repair <br /> -New Pump ft Pump Replacement a Pump Repair II Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method 0 Mud Rotary ❑Air Rotary n Auger n Cable Tool ❑Push Point Other <br /> Proposed Well Depth R Excavation in diameter ❑Open Bottom F.Gravel Pack/Gravel Size in diameter <br /> FJ Conductor Casing In dlaireler / Conductor Casing Depth fl <br /> Well Casing Diameter In Thickness/Gauge/ASTM Schell D Steel 11 Plastic 0 Stainless Steel 0 Other <br /> Grout Seal Depth 11 ❑Neal Cement(941b bagG540 gal nater) U Sand Cement sack mixR gal water <br /> Bentonite(20%solids) I I Other <br /> Grout Placement Method C Pumped ❑Free Fall I Other D Retardant/Accelerator(name) <br /> PEDESTAL Installed By D Driller ump Contractor U Other <br /> Concrete Pedestal n0imenslons:Width It Length It Thick in D Christy Box n Stove Pipe <br /> Pu1.tP Submersible Turbine ❑Other HP Pump Sel 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 /> 141MUM 40 HOUR ADVA C NOTICE REQUIRED F I SPEC IO P ASE CALL(209),9 3-769 <br /> SIGNED TITLB DATE l� <br /> 6 <br /> I <br /> F <br /> ©5 2019 <br /> '� <br /> FCOO <br /> 9� �� <br /> a <br /> PA TMENT 4SE)ONLY <br /> jf <br /> Application Accepted By Date Area Employee I D#1S1�1C_l' <br /> Grout Inspection By ,,��tt Dale ❑ SPECIAL Well Perin It <br /> Pump Inspection By �1��'A'UVA kW Dale ❑ WAIVER Received <br /> Soil Boring Inspection By Dale Constructed Well Depth It <br /> COMMENTS <br /> PE Sc Received Check#/ Arnounl ale PormlU Invoice# Well ID# <br /> Codes Intogash Remitted pS Ice uesl# <br /> S Z -� (u <br /> EIID 43-06 r is.d 411018 //_ 87-7 I Z 3 3 WELL rPUL!P PERMIT <br />