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WELLIPUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1668 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)466420 <br /> NON-REFUNDABLEPERMIT <br /> p / /CALL 209 953-7697 FOR INSPECTI S EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS <br /> UFRIZ tow, Gn�`�cYM Qom, YY4-9QN�CITYAIP Irk of) <br /> m <br /> —� D <br /> CROSS STREET N� ur'j t�l tF}t� APN Z 5'006 10041 PARCEL SIZE A*Cdj-AND USE APPLICATION# a <br /> OWNER NAME �YI,IC� P4GatIL RMgr7�HONE�</pz) yY-SOL70 N <br /> 19th Llo�ala� Si�reG-I- �Wa�n4 & ,6 �og1 q <br /> OWNER ADDRESS CRY/STATEIZIP 3U <br /> CONTRACTOR !, CAQA e914 o[" IIA(-. _ PHONE Crjw OSZ�9�I <br /> CONTRACTOR ADDRESS p J CRYISTATE/ZIP <br /> SUBCONTRACTOR Y+�VJ Dn IIIKL/ _,'1 1' PHONE <br /> SUBCONTRACTOR ADDRESS_1133 51"k6r-j+1 C.TYISIATE/ZIP�Q I4 :54j2- <br /> CA <br /> 6 � <br /> LICENSE C-57 E <br /> 61 ❑D-09 D Other NUMBER g EXPIRATION DATE 7-0 <br /> DOMESTIC WELL SAMPLING:n General Mineral/Coliform Bacteria(4391)n Dibromochloropropane(4392)n Arsenic(4393) <br /> INTENDED USE 7 Domestc/Privale D Irrigation/Agricultural F Industrial ❑Water Quality Monitoring Soll Sampling/Characterization <br /> .1 Public Water System <br /> If diffinera Iran Owner. Water System Name Conrad Neme W Phone Number <br /> TYPE OF WORK 7 New Well G Replacement Well E Well ALeralien/Medification 3 Other <br /> Monitoring Well(s) #of wells E Soil Boring(s) #of b°dngs Geotechnical 1 ff #of lxmrgs <br /> Out-Of-ServiceWell C Out-Of-ServiceWall Renewal 0 Cross-Cenneclion Repair q�r <br /> -1 New Pum -1 Pump Re lacement n Pump Re air IT Raise Well Casin <br /> WELL CONSTRUCTION * J�Iii �. /!t r p <br /> Drilling Method -1 M d otary n Air Rotary IXAuger n Cahle ool 7D Push Point n Other <br /> Proposed Well Dep /J it Excavation(_in diamete- L Open Bottom L Gravel Pack/Gravel Size_in diameter <br /> D Conductor Casing in diameter i Conductor Casing Depth ft <br /> Well Casing Diameter ' -n Thickness/Gauge/ASTM Schad L Steel C Plastic �Stainless Steel I Other <br /> Grout Seal D J P, Neat Cement(94 16 bay5-10 gal water) E Sand Cement sack rn&U gal water <br /> Bentonite(20%Sol ds) ❑Other <br /> Grout Placement Method Pumped D Free Fall 7 Other 3 Retardant/Accelerator(name) <br /> PEDESTAL 11,k Installed By i i Driller I Pump Contractor I Other <br /> Concrete Pedestal❑Dimensions:Width ft Length ft Thick in ❑Christy Box 0 Stove Pipe <br /> PUMP Wj Ar -1 Submersibles Turbine, IT Other HP Pump Set It Standing 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 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 /> P <br /> N49 HOUR A[yAaCE NOTICE REQUIRED FOR IN ECTIONS-PLEASE CALL(209)953-7697imD vI:5e <br /> SIGNED ,`CJ TITLE r ATE Z ­ <br /> � �1 I '. <br /> Joq 2419 <br /> TH p�oq�NT uNry <br /> TMFNT <br /> ),pr' AR ENT U E N Y <br /> Applicatlon Accepted By D to Area Employee 11 <br /> 4� � <br /> Grout Inspection By Date ❑ SPECIAL ell Permit <br /> Pump Inspection By Date --}�-���--��(--,+��+-- ❑ WAIVER Received <br /> Sol[Boring Inspection By :NLk —/ <br /> Date l Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Recelved Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info Cash emi"e Service ues # <br /> / <br /> EHL 4}po reWsea 4/tuna 1 Ji/��7 n/�j�� WELL IF<;MP PERMIT <br />