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WELLIPUMP PERMIT <br /> SAN JOAQUIN('owrry ENVIRONMENTAL FlEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE--'STOCKTON CA 95205-.6232 (209)468-3420 <br /> NON-REFUNDABLEPERMIT 4Le h d EXPIRES 1 YEAR FROM DATE ISSUED <br /> J) <br /> L <br /> 0 F3 A D D /j CITYIZIP M <br /> rj RFS5 . <br /> CROss S rRFFT fl 0 <br /> PARCEL SIZE LAND UsL2 APPLICATION# 0 <br /> 0WNrk-NAME PHONE <br /> r CiTYjSTArE/ZIIA <br /> )WNERADDR�r,ss ot 377 <br /> CONTRACTOR Ay— <br /> '?77--/Y <br /> I <br /> CONTRACTOR AnnRrss _2 CITY/STATE/ZIP <br /> :ON�rRACIO /CONSULTANT <br /> C,71'Lll.-NTRf:,:I>/CONSULTANT ADDRE+S CITY/STAT[/ZIP <br /> LICENSE Sr 1 1 C-611 11 D-09 i I Other NUMBER?ZO 170 Y _­ EXPIRATION DATE <br /> BILLING PARTY: OWNLFZ CONTRACTOR SUBCONTRACTORICONSULTANT <br /> DOMESTIC WELL SAMPLING: (-;I-Ilel'@IMiiieral/ColiforillBacteria(439-1) Dibi-oi110c;hloi-opi,opane(4392) Arsenic(4393) <br /> INT' nrt_)UsE I.i Domestic./Private _1 Irrigation/Agricultural I I Industrial FiWater Quality Monitoring ti Soil Sampling/Characterization <br /> PtII)Ijc 1Afatc-!I*Systralj) <br /> If different Irom Owner: Water Systvio Nairiv Contact Naive or Phone Number <br /> Tyi-,E OF WORK n New Well r I Replacement Well I I Well Altpi,,,ltioi)/Modifi(:.,.itioii 11 Other <br /> 15 Mot1ijC)IiIjqW(1.II(S) #nfwells Ij Soil Poring(s') iF <br /> of borings 46 f of borings <br /> t i Oul-Of-service Well 1) Out-Of-Service Well Renewal LI Cross-Connection Repair <br /> New PiInlp I i Ptunp Replacement LI Pump Repair <br /> 1) Raise Well <br /> Casing — <br /> WELL CONSTRUCTION- <br /> Drilling Method 1 1 Mud Notary Air Rolary KAugei I I Cable Too[ I I PLISh Point I i other <br /> Proposed Well Dojlth0_261 11 Excavation in diameter II Open Bottom 1: Gravel Pack/Gravel Size in diameter <br /> I I Concluctor Casing___in diameter / CondUCtal Casing Depth It <br /> Well Casing Diameter ____ in ScheelI I Steel 11 Plastic I I Stainless Steel 17 Other <br /> Grout Sea] _fl KNuat Cement(94 11)bag/5-10 gal waten) I I Sand Cement— —sack tm.Y17 gal water <br /> I Bentonite(20%,solids) I 1 011-let <br /> Grout Placement Method f t PUrrijed J I Free Fall W_0Iher'_(Xt-t%LA- I Retardant/Accelerator(name) <br /> ------------- <br /> FLIED 1_1 L�L Installed By !_j Driller I I PUITIP Contractor 1-1 <br /> I I Concrete Pedestal I-)Dimensions:Width_It Length 1`1 Thick in 1-1 Christy Box LI Stove Pipe <br /> Submersible I I I urbine I I Other HP Pump Set__ It Standing Water Level ft <br /> I FIEREBY CERTIFY THAI' 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 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MINI M 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)966 <br /> -7 97 <br /> SIGNED TITLE DATE.- <br /> ji, <br /> ------ Z�b <br /> Q <br /> Alt'. <br /> .......... <br /> Cr E R T It/I E: N T U 0 L <br /> Applicntion Accepted 1 Date lor Are:: Linployee IDI/P P <br /> 'If e <br /> Grout Inspection 1_ty Date 11 Permit <br /> P111111)Inspection By Date WAIVER Reccived <br /> Soil Boring Inspection Fly Date Constructed Well Depth <br /> ol,.IMENTB <br /> T <br /> _R_0 60 1 v a I Amount Date Ponnitt Invoice# Well ID# <br /> s i Remitted Service Request# <br /> a <br /> VON 0- 111 <br /> WELL/PUMP PERM IT <br />