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WEWPUMP PERMIT <br /> SAN JoAQLm Coulter ENA ROt�RAL HEALTH DerAH716R 1868 EAST HA�Tw AvP3tkrE-STOatTal CA 95205-(2t19) 34� <br /> NON-REFUNDABLE PERMT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> Joe AoORESS c�TrlZ r <br /> C3toss STRW, /Yl p,4, n IIPN J y J v I i Y.SME Lwe® T,oN s g <br /> Ovvwal NAmE I <br /> OWNERDo�ss sC111^r' Cnv1STATErzr <br /> G <br /> CONTRACTOR <br /> CONTRACTOR Ai4AC—r-,ATE/ZPA. <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR AMREss Crrr/STAT EMW <br /> Llt� ❑C-57 C-61 ❑D-09 C Other NLMSER�0�7� ! EJIPRATIONDwTE \ ��✓"u <br /> Do Esm WELL :❑General MnerallCofifam Bacteria(4391)❑Dllxomochioloptopane(4392)U Arsenic(4393) <br /> 1t n trdm2tiontAomthrnl . IMusmai ❑Water Duality Abtulorit9 ❑SW <br /> ❑Public Wailer System <br /> ca lad Hank or Pea.H-6. <br /> x aaaea can o.�r Warm 9yen+t+�a�e <br /> TYPE OF WORK ,dew Wei 0 Repimement Wc-0 ❑Well AlferabOJNodilicalion ❑Other <br /> G Mmdonng Well(S) sof veft ❑Sd Borvg(s) s W bmf ❑Geobe x ----� b— <br /> won ❑out-of-Service Well Renewal ❑CtassC�Repair <br /> ❑PLmp Phoacernent ❑Pump Repair ❑Rase Wei Casing <br /> WELL CONSTRUCTION <br /> Dnitvlg Med od O Mud Rotary ❑Ac Rotary ❑Auger L Cable Tod U Push Pant 0 Other <br /> Proposed Well Depth ft Excavation in dmreter C Open Bottom G Gravel PaAC avel Size in diameter <br /> G Ccnldkletor Casng n&ameYu / Conductor Casing Depth It <br /> Well Casing Diameter_in Thmduves7GargefASTM Schell ❑Steel O Plastic ❑Starless Sled G Other <br /> Grout Seal Depth ft n Neat Cement(94 M bag/5-10 gal meter) ❑Sand Cement sack mbd7 gal water <br /> ❑BemmnOe(20%sD&is) D other <br /> Grout Placement Method ❑Pumped ❑Free Fag ❑Odw C Retardant I Accelerator(name) <br /> P®ESTAL tPlylaW By 0 DW RV.W Contractor ❑ OOrer <br /> eerlcretr Pedestal CDtrinnsiorns:vylaon fl Lnxgsl ft Ttsc}k in ❑Christy Box D Stove Pipe <br /> Suhrrtrrsitlle❑Tubule C Oona HP PustuP R Starring water Level fl <br /> I HERESYRK CERTIFY THAT I HAVE PREPARED THS APPLICATION AND THAT THE WOWILL 13E DONE IN ACCORDANCE WITH SAN <br /> IOAQUIN COUNTY ORDINANCES,STATE LAWS. AND RULES AND REGULATIONS_ 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CAUFORICA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS 7ENSATION LAWS. <br /> !MUM 4S H R ADVANCE NOTICE REQUIRE ED FOR <br /> ��INSPECTIONS <br /> �-PLEASE CALL(209 953 7697 <br /> SICIm <br /> TTcA,[f V4 KUY DATE <br /> THITW <br /> gI I LAc MFNT <br /> y 2020 <br /> C <br /> 4IENO CNTy <br /> �RTMENT <br /> L DEPARTMENT SE ONL <br /> caY <br /> AppYtian Accepled By �3 JA D Area Employt•e of <br /> Grad Inspection By Data f ❑ SPECIAL Well Permit <br /> Pump Inspection By_, f 0�^ 6 S L O_1ge_YYla Dfb �Z,\1.�1Ct� ❑ WAIvER Received <br /> Sod Bonn Inspection By Date Constructed well Depth It <br /> COMMENTS <br /> PE SC RNclilled Gheckfl Amount Dat. Parma Invoice! Well IDs <br /> Codes Info Casb Remitted IRequestrrs <br /> eT043-05 MVNd4f14ne 176 <br />