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a06 4 DUD 4�3 <br /> WELUPUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELToN AveNuii-STOCKTON CA 95205-(209)408-3420 <br /> NON-REFUNDABLE PERMIT CALL(209)953_7697 FOR IN PECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOD ADoness '� .CITYIZP FbC- _ <br /> �,� ,, �� �1 �+� (�} tmy� <br /> CROSS STREET /•v►l 6or AVC ,APN e�Sa►^�/�� PARCELSIZE( � LAND USE APPLICATION# _ 0 <br /> OWNER NAME G t T I V ��� �/ l�U j)t-1 r1�S PHONE 2( 1� S'Slx_- 33 '^ <br /> OWNER ADORES$ 3 Q H 0 CITYISTATEIZP ��-r-t� C-4-y qS;0 1- <br /> � <br /> CONTRACTOR Y TOS• ���,1` vifc� PHONE /�4—'� <br /> CONTRACTOR ADOHE99_ CnYJ5TA7E/ZIP ^ <br /> SUBCONTRACTOR PRONE <br /> SUBCONTRACTOR ADDRESS C"WSTA7EIZP <br /> LICENSE G57 -C-61 [I D-09 r Other NUMBER 199 s/ EXPIRATION DATE •_ �_ <br /> DoMESTIc WELL SAMPLING: General MinerallColiform Bacteria(4391) Oibromochloropmpane(4392) Arsenic(4393) <br /> INreNDEoUsE .- DomesliciPrIvate- 0InigalionfAgricuttwal - Industrial _.Water OuaiityMoniloring -Soil Sempling/Characlerization - <br /> :.Public Water System_ _ <br /> ITdlNamm tmm O—C. Warcr Systa n Nena Conran Name or Phom�umSm <br /> TYPE OF WORK New Well - Replacement Well -.Weli AlterationlModifcation (Other <br /> MonRorNliVeilts) _#ofwelts - SDilDoring(s) aMsonnax Geotechnk:alvW,Yaornor,ngs <br /> out-Of-Service Wall "Out-Of-Service Well Renewal Cross-Connection Repair <br /> i New Pu_m�_.Pump Replacement t Pump Repair Raise"'ell Casing <br /> WELL CONSTRUCTI N <br /> ` <br /> Drilling Me@led Mud Rotary r Air Rotary Auger Cable Tool Push Point )ICOrher r- #\ d•L. _ <br /> Proposed Well t?eplh-. QA_ h Fxcavallon 113_in diameter Open Bottom Gravel PacklGravel Size_ In diameter <br /> Conductor Casing In diameter I Conductor Casing Depth ft I <br /> Well Casing Diameter in l'nlCknesslGaugelASTM Schell -Steel I.Plastic-Stainless Steel -jthe <br /> Or .___ <br /> Grout Seal Depth.k, _.-_-rt Now Cement(94 Ab 1)ag5-10 gal hater) I>tSand Cement I o —sack mixO gal Walel <br /> :-0entontic(20546 solids) .:Other <br /> Grout Placement Method Jumped 7 free Fall -Other- 7 Retardant)Accelerator(name) <br /> P[aeSTwL Installed By� Driller - Pump Conlroetor Other� Concretede <br /> Pestal Di rnsr ensloWidth it Length it Thick in Christy Box ❑Stove Pipe <br /> (�PUMP Submersible-Turbine - Other HP Pump Sal H Slanding Water Level_ R <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COU14TY 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 /> MIN 49110 A OTIC EQUIRFE)FOR INSPECTIONS-PLEASE CALL(209)953-' 9� <br /> SIGNED TrTLE ✓+G DATE <br /> Zze <br /> PA <br /> NOV <br /> 4 V <br /> - APR 2 2 2019 <br /> I� JOAQI) <br /> I I Nv(RoN N NTUNTM <br /> - -r HEALTH�EPARTM I <br /> ENT <br /> f L LL.1--1 --- --- <br /> id <br /> ' <br /> 77-1-1 <br /> Pj4 MENT E O LY <br /> Applicalion Accepted By DRI• _ Area Employee ID# <br /> Gmut Inspection By c Dato J SPECIAL ell Permit <br /> Pump Inspection Date 1 WAIVER Received <br /> Sod Boring Inspection By Date!- Constructed Well Depth It <br /> CONWENT5--_—._--- -_.--.T-- --._--- <br /> PE SC Reeahred Chackdi Amount now PermiU Involestt Well 10# <br /> Codes o Cash Remitted Service Request F <br /> "D 43.06—i-d 4114114 QD�{-1 7 / / WELL rUNP PFRAIR <br />