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` WELUPUMP PERMIT <br /> SAN JOAQUIN CouNTY ENV6toNMENTAL HEALTH DEPARTMENT` .186&EAST HAZ L-11DN AVENUE-STOCKTON CA 95205-(2091468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7597 rOR INSPECTIONS EXPIRES I YEAR FROM DATE:ISSUED <br /> 'tet ,7 A� L� M /�q p`�j� � <br /> Jos ADDRESS Jy� 1� t o m e l li m. � n __ CITYJ7JF' F'\Ct l�*0 rf I CA /J J,�_._�— D <br /> CROSS STREET=`& p� L ,t' AFNI�/'�� d�l7 PARCEL SIZE1Q tAtJp USE'7A�PP�DCArTi_O1N9# !,1 •� y <br /> OWWR NAME PA R1,, � !\1 G C../_ pPHONNEE.GwiJf-1•IYf G+r 01 3 L 9! <br /> OWNER ADDRESS Q�� —�2�1 CrfYISTATEMP—-P�1�w7�r1 e/Iq/✓-7� <br /> CONTRACTOR (il\n. C0.A1 •''� SPA PHONE ZD 1•-7[/a� • (o,2-7Ia <br /> CONTRACTOR ADDRESS PSI Ott •-t L�C. f7�10_ 2A , CrryiSTATEOP�(yVL�ec� i �1� 16131a <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITYISTAT=J73P <br /> LICENSE 0 C-57 ' C-61 D D-09 D Other NUMBER /D)� q(o EXPRATIONDATE 3 I Z0 2 <br /> Doptt=_sTtc NIELL SAmPuNG.C General MinerallColiform Bacteria(4391)C DibromoclTloropropane(4392)0 Arsenic(4393) <br /> IN'rlyDED USE X DomestidPdvate(.2.Irrigs*oNAgricuttumt Cr industrial _,j`AJater Quality Monitoring L Sod SamplingrCharecterization <br /> D Public Water System <br /> Irdfroremfrom Owner: JYatlr SyM—Name Contest Name or Phone tiumoer <br /> TYPE OF WORK C New Well D Replacement Welt C�Well AltorationMladlflcaliort D Other <br /> 0 Monitoring Weil(s) #afwells O Soil Bodng(s) <br /> tl etberinga 0 0eotechnical Totbarings <br /> C Out-Of-Service Well C Out-Of-Service Ntell Renewal 0 Cross-Connection Repair <br /> New Pump c Pump Replacement D PUITV Repair "I Raise Welt Casing <br /> WELLCONSMUCTION <br /> Drilling Method 0 Mud Rotary D Aa Rotary C Auger O Cable Tool a Push Point D Other <br /> Proposed Well Depth ft Excavation in diameter D Open Eattom D Gravel Pack/Grave!Size in diameter <br /> 13ConductorCasing in diameter I Conductor Casing Depth It <br /> Well Casing Diameter_in ThlcknessiGaugeIASTM Schell C Steel O Plastic O Stainless Steel D Other <br /> GroutSeal Depth it O Neat Cement(94 to bagl5-10 gal water) D Sand Cement sad*miur7 gal water <br /> O Bentonite(20%Solids) D Othe: <br /> Grout Placement Method 0 Pumped 0 Free Fail 0 Other _U Retardant J Acsetemtar(name)- <br /> PEDESTAL <br /> name)PEo STAL Installed By EI Driller O Pump Contractor 0 Other <br /> O Concrete Pedestal CDimensions:Nftdth R Length ft Thick in O Christy Box I I Stove Pipe <br /> Pump Submersbte0 Turbine 0 Other HF Pump Set ft Sland'uIg Water Levet y <br /> 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION ArND 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 WI THE FORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM INCOMPLLLNCE WITH ALL <br /> WORKERS COMP ISA WS. <br /> MINI H 1 AN NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953 7697 <br /> SIGNED <br /> TITLE ✓ Fi'Ll� DATE <br /> j <br /> 1 <br /> YMENT <br /> I CEIVEp <br /> I I <br /> V 2 7 2019 <br /> ONMEN�TqN TY <br /> I —FT DEPgRTMENT <br /> t <br /> I <br /> A TME NWUP E O LYPpp&ca5on Accepted By ate .a Area l EmplUyee[D#���J�� a���•_•� <br /> Grout Inspection By Date ❑ PECIAL Weil Permit <br /> Pump Inspection By Tfe.�rF..�t.e 'L 1. Date 416 1 1A) 7 WAIVER Received <br /> Sol Baring inspection By Date Constructed Well Depth_Ft <br /> COMMENTS - <br /> PE SC Received Check#! Amount Da. PennitJ Invoice A Well ID# <br /> Info B sh emitted Service Request <br /> --- wELL4FUMPPERM4T <br /> Ek�4106 revived 41tprse <br />