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WELUPUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - SrocicroN CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS I" v i 6 i I ciTyrzip KIA\11.GGL, GI 9Lp <br />I <br />CROSS STREET • <br />i 1W,T, <br />A tilnilea. APNVO "0% . OD PARCEL SIZE LAND USE APPUCATiON it <br />OWNER NAME Li It WE 0 CA' PHONE <br />OWNER ADDRESS I)12-- "[MAGNA GIR CITY/STATE/ZIP t ArAktak, cA cp-”kip <br />CONTRACTOR1\1\6160 .1t 114 V 1104iNci• PHONE 204- 12..412- <br />fs rii, • CITY/STATE/ZIP tonclo (A 191/51 CONTRACTOR ADDRESS Ai <br />1 <br />SUBCONTRACTOR PHONE <br />SUBCONTRACTOR ADDRESS CITY/STATE/LP <br />LICENSE XC-57 E C-61 ri D-09 0 Other NUMBER ikilbW120. EXPIRATION DATE 04 .9)02.02-1 <br />DOMESTIC WELL SAMPLING: u General Mineral/Coliform Bacteria (4391) U Dibromochloropropane (4392) o Arsenic (4393) <br />INTENOED USE XDomestic/private C Irrigation/Agricultural 0 Industrial 0 Water Quality Monitoring Cl Soil Sampling/Characterization <br />0 Public Water System <br />If different from Owner: Water System Name Contact Name or Phone Number i <br />)/TYPE OF WORK New 0 Well 0 Replacement Well Well Alteration/Modification 0 Other <br />C onitoring Well(s) 0 of wells 0 Soil Boring(s) • of borings 0 Geotechnical • of borings <br />i <br />: Out-Of-Service Well 0 Out-Of-Service Well Renewal 0 Cross-Connectlon Repair <br />C New Pump 0 Pump Replacement E Pump Repair C Raise Well Casing S 'V WELL CoNsTRucTioN <br />Drilling Method)<Mud Rotary I Air Rotary C. Auger 0 Cable TOOI -I Push Point 0 Other <br /> <br />Proposed Well Depth ft Excavation ‘VI in diameter C Open Bottom XGravel Pack/Gravel Size l 10 in diameter7 .-15D <br />El Conductor Casing in diameter / Conduct gasing Depth ft <br />Weil Casing Diameter ID in Thickness/Gauge/ASTM Sched jAJU 0 Steel XPlastic Cl Stainless Steel 0 Other <br />Grout Seal Depth 1.-001 ft 0 Neat Cement (94 lb bag/5-10 gal water) 0 Sand Cement sack mix 17 gal water <br />XBentonde (20% solids) El Other <br />Grout Placement Method XPumped :1 Free Fall 0 Other 0 Retardant (Accelerator (name) <br />PEDESTAL Installed By 0 Driller 0 Pump Contractor C. Other <br />.] Concrete Pedestal :Dimensions: Width ft Length ft Thick in Cl Christy Box 7 Stove Pipe <br />PUMP E SubmersibleLI Turbine 0 Other HP Pump Set ft Standing Water Level ft <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT <br />JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. <br />CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE <br />WORKERS COMPENSATION LAWS. <br />MINIMUM 48 HOUR ADVANCE NOTICE REQUIRED FO <br />TITLE <br />Sp <br />THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br />I ALSO CERTIFY THAT MY REQUIRED UCENSE IS <br />BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />CT ONS - PLEASE CALL (209) 953-7697 <br />DATE tl.t1-1414 k/t,..,....„..,,_ <br />nail liN <br />doi 4------, 3, , <br />44-N- <br />..' <br />1.0. 3-1. g1-011CO \ eteA 5-7 I <br />nit -12-1.1Vr2:12- <br />DEPARTMENT USE ONLY <br />Application Accepted By 6-.5-- - Date <br />Grout inspection By 111•All t• <br /> y <br />Date ( I /1., <br />Pump inspection By Date <br />Soil Boring inspection By Date <br />Area 3 Employee ION r <br />0 SPECIAL Well Permit <br />D WAIVER Received <br />Constructed Well Depth ft <br />COMMENTS X <br /> <br />PE <br />Codes <br />SC <br />Info <br />Received <br />B <br />Check*/ <br />Cash <br />Amount <br />Remitted <br />Date PermfV <br />Service Re ue t # <br />Invoice # Well ION <br />4.3 44% / FO a, ( ‘Ct4 VitR3 J,1 1 I 3t: Lici.• t Y rY/ <br />ll PIS— 'ili vi,(A.',-tU-,,.-'q l <br />LI 3<7,22 o P-50--- .7 '' II i 24; 1,t4 ' 0! I-16 <br />• <br />WELL /PUMP PERM! <br />us <br />/632? 7(37 <br />EHO 43-08 8/01/18