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WELUPUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT- 1868 EAST HA2ELTON AVENUE-STOCKTON CA 95205-(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESSMill "i ANA C1rYf71P M04#100', 61 933tD <br /> fpsuft ?A1,04 4�i0.1�� � > <br /> CROSS STREET A O- APN PARCEL 512E LAND USEAPPLICATION# o <br /> OWNERNAME `tier v ,fI/PHONE <br /> OWNER ADDRESS 1 I� GINPA 1 (I/ CRYISTATEMP p111AN�CJC ..�/��i�] y/i/%�'J�/1' <br /> CONTRACTOR 4 1' - N( - . P�H�ONr L/ A' 11.1AL <br /> CONTRACTOR ADDRESS t1A CTTYISTATE/LP O W/ ,01A <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS C,ReYISTATVLP <br /> LIGENSC C.57 ❑C-6110 D-09 ❑Other NUMBER V EXPIRATION DATE O <br /> DOMESTIC WELL SAMPLING:D General Mlneral/Coliform Bacteria(4391)0 Dibromochloropropene(4392)O Arsenic(4393) <br /> INTENDED USE DOM°eUdPnvale 0 Inlgallon/Agriculturel O Industrial 0 Water Quality Monitoring 0 Soll Sompling/Characlerizadon �� <br /> D Public Water System ECe EN7� <br /> ff 01-1 from 0— WII.r Syrlem N.— Contact N.—Nemo w Phone Number I <br /> TYPE OF WORK New Well O Replacement Welt 0 Well Alteratlon,Modlficellon 0Other /VES <br /> 0 ondoring Wells) Is Of wells 0 SOII BOdng(s) 6 of lwdrge 0 Geotechnical a albadngs AY <br /> e 0Out-Of-Service Well D Out-Of-Servlce Well Renewal 0 Cross-Connection Repair 122020 2 2020 <br /> O New Pum D Pum Replacement D Pum Repair 0 Raise Well CasingUL <br /> WELL CONSTRUCTION Q(J <br /> Drilling MethodXMud Rotary 0 Air Rolary 0 Auger 0 Cable Tool O Push Point ❑ Other N��N FRONMECOUNTY <br /> Proposed Well Depth'nf)* ft Excavation�i _In diameter D Open Bottom XGraval Pack/Gravel Slzel_In dlamete OEPA TAI <br /> 0 Conductor Casing In diameter I Conduct basing Depth R MENr <br /> Well Casing Diameter 19— Thlrknesa/Geuga/ASTM Schad ' D Steel Ptestic ❑Stainless Steel ❑Other <br /> Grout Seal Depth 1,W' 111 0 Nest Cement(9I It,be915-10 981 water) ❑Send Cement sock m&11 gal water <br /> XBenlonde(20%solids) D Other <br /> Grout Placement Method kumped 0 Free Fall D Other D Retardant/Accelerator(name) _ <br /> PEDESTAL Installed By 0 Driller D Pump Contractor 0 Other <br /> 0 Concrete Pedestal ODlmsnslons:Width_ft Length R Thick In ❑Christy Box 0 Stovo Pipe <br /> PUMP 0 Submeralblell Turbine 0 Other HP Pump Set ft Standing Water Level it <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 WfTH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MINVAUM 48 HOUR ADVANCE NOTICE REQUIRED FOFZ,( S-PLEASE CALL(209)953-7697 <br /> SIGNED_ TITLET Ii/��/Y��. DATE <br /> ------------ N <br /> --------------------------------- <br /> ----------- <br /> ------EEO al 14 q T N----$*-- — <br /> l <br /> DEPARTMENT USE ONLY <br /> l� <br /> Application Accepted By �7'r ! Date OCL7 Area Employee ID# <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soli Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC <br /> Received Chock#! Amount Dat° Pannit/ Invoice# Wall IDN <br /> Codes Info B Cash Remitted servICORO ue t# <br /> 97�Jy WELUPUMP PERMIT <br />