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WELLJPUMP PERMIT <br /> SANJOAOWIICOUNTYENVIRONYENTALHEALTHDEPARTNwmT 1[6SEASTHAmTOHAvr�lue-STOCKTONCA[52115-6232(209)46B3420 <br /> NON-R!<FUNDABLEPERm' yWYW.ffQpyprWehd EEWIRRE_S—_'IYEAR FR pDyA�TEIS8UED_ <br /> Oil ADDRESS ' eG:./"'"S✓ Vyr O ` DRY/IIP TP�Y/YJr�I✓•� 77 - - <br /> ACROSS STREET t f,e or Fxc r/ APIN_ f` I v --� <br /> /��y { ARC[L Sa[ LAND USE APPLICAATIM#// �} �y <br /> OWNER NAME oewyyR S PHONE 2�•�`rb IJ �OOV <br /> OWNERADDRESS /7/G/ISIr �7ye Cf I1WA.MP/f!C�J7.P <br /> a ' <br /> V 1" CONTRACTOR c��N/O�P �SSCLAj '�.J�A PHONE. 9�I 7��-7 .7 ex �Z <br /> 10 <br /> V��n�\ CONTRACTOR ADDRESS//Oe .P c/�G/ n . L;&0 T TCI rsTATf/Zm.Sa C rA fil c 4 _l�7!i <br /> Y SUBCORTRACTDHICOHSULTANT rO�L�X -i0e.4/ /! (9/1) <br /> J� PHONE IC <br /> d 6�^/ �/� <br /> SUSCONTRACTOOW�WCONSULTANT ADDRESS J SAO I/ 6 F�T ke CIrTYlSTATEIZP J),X 0j1I/C.A/ /, v i(/ <br /> L=Dm We 57 ❑C-61 ❑D-09 ❑oe»r / NumaER J a 7 EID IRAmN oATE- /1 J a <br /> BILUNU PARTY: ❑OWNER ❑CONTRACTOR R<U-- MIIACTORICONSMTANT <br /> OOMES=Wm.L SANIPU11G:C General Mineral/CoBbrm Bacteria(4391)❑Dlbronlochbropropane(4382)❑Arsenic(4893) <br /> P ❑DomestiuPrivele-- ❑Irtge6nAQieukObdusNl O Water Monitoring laeSamCharacteraatio—nurel 6pling � <br /> L Public Water System <br /> MddknntM1an Omer. -- WekrBretem Nine ..---------- t:arWa Nemo er PNsrw lWMer <br /> TYPE OF WORK ❑New Wee ❑Replacement Well ❑Wag AlteratoWodification ❑Other <br /> ❑Monitoring Well(s) #of weRa ❑SoIIBcrfng(s) V GGeotechniCal_•Z_sorbarkw - <br /> ❑Out-Ol-service Wee O Out-Of-Service Well Renewal ❑Croea•Connection Repair <br /> WELL ❑New PU_m.. O Pump Replacem/ent D Puna Repair ❑Rabe Well Casing <br /> Drilling Method Mud Rotary ❑Air Rotary ES Auger ❑rCable Tool C Push Point ❑ Otl»r_, <br /> Proposed Well Depth ll S-so R Excavation.�r�in diameter G Open Bottom ❑Gravel PaddGravel Slur In diameter' <br /> ❑Conductor Casing In diameter I Conductor Casing Depth ft <br /> Well Casing Diameter_in ThicknessiGaugelASTM Schad ❑Steel ❑Plastic ❑Stainless Steel D Otter <br /> Grout Seal Depth 14-'.0 ft edea(Cement(94 1b bag/5-10 gel water) L Send Cement sock mixl7 gal water <br /> ❑Bentonitey�2p%Wids)�❑Other ... - <br /> GMI:PlaprtwMMethod 1n,"Ped 7FraeFail ❑Other _.._. D Retardant/Accelerator(nerna <br /> Installed By ❑Driller ❑PunpContractor ❑ OBIer_—_---- --- <br /> ❑Concrete PedvSW ODlm inslons:Width 4 Length ft Thick In In ChrbtyBon ❑8wve Wee <br /> PIIMP D Submersible[]Turbine ❑Other____ HP Pump Set ft Standing Water Lavel 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 LICEN3E 18 <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MI IMUM 48 H;.U AD CE NOTICE REQUIRED FOR INS TIONS-PLEASE CALL(209)953-776697 '^ Q <br /> /)� r DATE <br /> SIGNED-_1.Z�`-►ti TITLE 4 y <br /> C1�o� <br /> G F® <br /> 0 <br /> 'qQCOU <br /> 6 ?015 <br /> M-14 <br /> NT <br /> ZLA! MEQ.N <br /> T <br /> Application Accepted ByI -4 Noa� L { Employee ID# <br /> Grout Inspection By Date ❑ �ECWL W¢II Perrnit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspec8on Date Ceeabueted Well Depth ft <br /> COMMENTS 6( <br /> PE SC Recehnd Choc Mourn <br /> Codve -Info B Inial"/ Well IDS <br /> alooae wtao» WML~Pmlr <br />