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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY EmInRoeaItENrAE HEALmi DQ'ARTmcNT 1868 EAST HAzELToN AVENUE-STocKToN CA 9S205-(209)46"20 <br /> NON-REFUNDABLE PERMfT /CALL 209 953-7697 FOR INSPECTIONS EXPI111RES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 'Yo .,y Ct 55op 4,1'. CmrLP.f �s30 7 m <br /> CROSS STREET I f a r t APN,7(`J J P�O <br /> PARCEL SIZE LAND USE APPLICATION# O <br /> OWNER NAME C.+' `G 'tPHONE <br /> OWNERADDRESS <br /> CITY/STATEWIP <br /> CONTRACTOR 9M[• J�--�1U�✓n l��1 / PHONE <br /> CONTRACTOR ADoREss �y t� iY) �(D CmISTATr7-L kLA-_1 F'I• 7 .7 ��� <br /> SUBCONTRACTOR _-._. PHONE <br /> SUBCONTRACTOR ADDREss CmZISTATEI-71P <br /> LlcorsE ❑C-57 S1 ❑D-09 C Other N.ER ICS / <br /> 2 q E.,.DATE <br /> DOMESTIC WELL SAM G:❑General MineralifColiform Bacteria(4391)0 Ditxomochloropropane(4392)u Arsenic(4393) <br /> INTENDED USE fATomesiWPnvate G IRigationlAgricultural L Industrial Ll Water Quality Monitoring Li Sod SamplinglCharacleT¢ation <br /> E Public Water System <br /> Irdiff—d rmm Owner. Water System Name Contact Name or Phone Number <br /> TYPE OF WORN E New Well C Replacement Well C Well AllerationNodification C Other <br /> C Monhorirg WeI1(s) #orweils D Soil Boring(s) sabo`'nDs 7 Geotechnical sot borings <br /> C Out-OfSemce Well C Out-Of-Service Well Renewal D Cross-Connection Repair <br /> New PUrripLacement C Pump Repair C Raise Well Casi <br /> WELLCoNsT u—cii <br /> Drilling Method Mud Rotary D Air Rotary i-Auger LL Cable Tool _Push Point Other <br /> Proposed Well Depth ft Excavation in diameter C Open Bottom C Gravel PacIdGravel Size in diameter <br /> C Conductor Casing 61 diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Sched C Steel C Plastic C Stainless Steel u Other _ <br /> Grout Seal Depth It n Neat Cement(94 1b bag/5-10 gal water) C Sand Cement_ sack mix17 gal water <br /> Bentonite(20%solids) C Other <br /> Grout Placement Method C Pumped `Free Fall C Otter C Retardant I A,cccterdtor(name) <br /> PEDES AL Installed By 2 Driller ED Pump Contractor !j Other <br /> C1 Concrete Pedestal❑Dimensions:~h ft Length R Thick in C Christy Boz D Stove Pipe <br /> E &SubmersibleoTufbine C Other HP I Pump Se ft Standing Water Leel__47—/_tt <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. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> M I M U M Qi R ADVANCE NO T)%E REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED r^—�- TrrLE A #4 50j7,jjjf,1 OLUOf DATE <br /> 1 <br /> C --/ <br /> 2y Z020 <br /> - - V, <br /> hl <br /> MFNT <br /> I HI <br /> DEPARTMENT USE N L Y <br /> Application Accepted By l-�/��-v/J z— Date Lat0 yArea - ' / Employee ID# ✓f� <br /> Gmut Inspection By _ Deb ❑ SPECIAL Well Permit <br /> Pump Inspection By Dill own I'tdw C WAIVER Received <br /> Sal Bonrrg Inspection By Deb Constructed Well Depth R <br /> COMMENTS <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info Casb Remitted rvice t <br /> EMD 43-M reAmd 4(14!18 v/ELL/rvNP PERIJR <br /> 0)c/ <br />