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c , <br /> WELUPUMP PERMIT <br /> SAN JOAQNN COUNTY EwmomwmuL HEALTH DEPARTI®R 1668 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)4683420 <br /> NON-REFUNDABLE PERW 711D /� CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS � (/!, c Tyrzm /�• <br /> waa -140-Ot00 �p.� D <br /> CROa1 STREET APN PARCEL SRE !.ANO UfE APPLICATION a <br /> OWNER NAPE (1 PHONE�--Jq -Nil <br /> OWNER ADDRESe 1� CrTY/STATEMP t/l�l Cw q'7�f���/],, <br /> CONTRACTORfflaylli'S1I �/PPHHONE ILA-92L Ij 10 <br /> CONTRACTOR ADORESe Cn-ylSTATEMP 1 I II IALA r�J �3q7 <br /> SUBCONTRACTOR ��"-- PHONE <br /> SURCONTRACTOR ADI CRY/STATErZWP <br /> LICENSE %C-57 Cl C-e1 0 D-09 0 Other NUMBER_kkj2-2- E)MRATMN DATE <br /> DOMESTIC WELL SAMPuNo: General MineraUCollfonn Bacteria(4391) Dibromochloropropane(4392)0 Arsenic(4393) <br /> INTENDED USE DomftbdPrtvate ❑Inigatfon/Agrlwlhlral 0 Industrial 0 Water Quality Monitoring 0 Soil Sampling/Characterization <br /> 0 Public Water System <br /> It k.nt Born un Ower W.I.syme,Hama Cortes NarrIs kx Phew Nwnear <br /> TYPE OF WORK ,ew Well A Replacement Wen ❑Wen Afteretlon/Modification 0 Other <br /> 0 bonitoring Well(s) r of were D Soli Bodng(s) a w l 0 Geotechnical s f bmino• <br /> 0 Out-Of-Smite Well 0 Out-Of-Service Well Renewal 0 Cross-Connection Repair <br /> 0 New Pump 0 Pump Replacement 0 Pump Repair 0 Raise Well Casing <br /> WELL CONsTRUI <br /> Drilling Method Al Mud Rotaryr 0 Air Rotary 0 Auger ❑Cable Tool 0 Push Point 0 Other <br /> Proposed Well Depth it Excavation 17`In diameter 0 Open Bottom 0 Gravel Pack/Gravel Size In diameter <br /> 0 Conductor Casing In diameter / Condyctor Casing Depth ft <br /> Wall Casing Dieter,amin. TN&n"/Gauge/ASTM Sched Uf) 0 Steel Plastic 0 Stainless Steel 0 Otter <br /> Grout!seal Depth H 0 Neat Cement(94 1b bags 10 gal water) 0 Sand Cement sack mix!!gal water <br /> tonne(20%softds) 0 Other <br /> Grout PlacernarnfAethodl Pumped 0 Free Fell 0 Other 0 Retardant/Accelerator(name) <br /> PEDESTAL Installed By 0 Drifter 0 Pump Contractor ❑ Other <br /> 0 Concrete Pedestal❑Dlmenslons:Width ft Length R Thick in 0 Christy Box 0 Stow Pipe <br /> 0 Submersible❑Turbine 0 Other HP Pump Set ft Standing Water Level 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 LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CAUFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPUANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MINIMU OU VANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)95/3.7697 <br /> SIGNED TITLE DATE QA' _ <br /> I <br /> 1 t 11, <br /> M <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date Date J- I �./C Area I `" "/ Employee ID* L)� <br /> A <br /> Grout Inspection By Date 0 SPECIAL Well Permit <br /> Pump Inspection By Date 0 WAIVER Received <br /> Soil Boring Insp000n BXDate Constructed Wag Depth ft <br /> COMMENTS I' O 11 Q i�l - 1 t ; $ "I IJL' n(-� <br /> PE SC Rscsfved Amount P*rmw <br /> r..w.. IntO .—ftd Data R to Invoice 0 Well IDN <br /> 4370 , Xo 0 1 L 1_! <br /> << - <br /> �.5 2 ", <br /> Etm 4iue arotre WELL(PUMP PERW <br />