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PHONE <br />CITY! STATE/ZIP <br />rPF?"? 1 1 EXPIRATION DATE :S.331:1CICV 31.IS f: 1<: Area Employee ID# <br />1 SPECIAL Well Permit <br />WAIVER Received <br />DEPARTMENT DEPARTMENT USE ONLY <br />Application Accepted By _____-_.-.77- Z- 4--- Date <br />Grout Inspection By Date <br />Pump Inspection By C.1 `.' v,v \I:, i k_z k....w'st. ., 4%1- Date 'i 1 \ (-) h.(*) l'k <br />Date ft Constructed Well Depth Soil Boring Inspection By <br />COMMENTS s• *.,•lbt• icA: 6 <br />EHD 43-06 revised 4/14/18 WELL PUMP PERMIT <br />PE <br />Codes <br />7- ___ c. <br />SC <br />Info <br />Received <br />_By <br />CEIgg?ckt Amount <br />Remitted Date „ <br />Permit/ <br />Service Request /I Invoice /I Well 10# <br />().5.1 /O. /&7437 .1, ts ,2 42.V24 1.11p6U1-173c1 <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - Srock-row CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT CALL (209) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS // 3 c / 4.= / 0 ..fdy C OA ov), Z cn-yrzip Al crdi ..5'.-.XX I <br />CROSS STREET /44'4 Y.' (595 APN d CI -/ ?..-CMIer'PARCEL SIZE " LAND USE APPLICATION /I <br />- <br />OWNER NAME frl e e 0 Ay (-9 4- 6 4/1-v s. ‘ ),..- PHONE <br />OWNER ADDRESS / I 240 / e TZ.; I090 e-o,4, 0-ey /a CITY/STATE/ZIP <br />CONTRACTOR <br />CONTRACTOR ADDRESS .14.5 0 „ge <br />4 /4 PHONE .2e 9 qr.1- ?27$1 <br />CITY/STATE/ZIP S-11--04-.6.744 66.--:2145° <br />SUBCONTRACTOR <br />SUBCONTRACTOR ADDRESS <br />LICENSE 7 0-57 4,9-61 F D-09 E Other g NUMBER <br />DOMESTIC WELL SAMPLING: E General Mineral/Coliform Bacteria (4391) IF Dibromochloropropane (4392) IF Arsenic (4393) <br /> <br />1 ,41omestic,/Private D Irrigation/Agricultural Li Industrial Li Water Quality Monitoring 17 Soil Sampling/Characterization <br />El Public Water System <br />If different from Owner Water System Name Contact Name or Phone Number <br />TYPE OF WORK 0 New Well 12 Replacement Well 11 Well Alteration/Modification F Other <br />0 # of borings Monitoring Well(s) # of wells 1-1 Soil Boring(s) # of borings El Geotechnical <br />7 Out-Of-Servich Well 0 Out-Of-Service Well Renewal r- Cross-Connection Repair <br />X New Pump Pump Replacement Ti Pump Repair E Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method ri Mud Rotary I" Air Rotary F Auger 0 Cable Tool Ti Push Point 0 Other <br />INTENDED USE <br /> <br />Proposed Well Depth ft Excavation in diameter E Open Bottom FJ Gravel Pack/Gravel Size In diameter <br /> <br />0 Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched 0 Steel Ii Plastic D Stainless Steel 0 Other <br /> <br />Grout Seal Depth ft U Neat Cement (94 lb bag/5-10 gal water) U Sand Cement sack mix17 gal water <br />Li Bentonite (20% solids) u Other <br />Grout Placement Method U Pumped E Free Fall L: Other <br />0 Retardant / Accelerator (name) <br />PEDESTAL Installed By : Driller U Pump Contractor L. Other <br />Ti Concrete Pedestal :Dimensions: Width ft Length ((Thick in Ti Christy Box IT Stove Pipe <br />PUMP ok,SubmersibleE Turbine El Other HP 3 Pump Set -iyz ft Standing Water Level I 2-7, ft <br />WORKERS COMPENSATION LAWS. <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 WITH ALL <br />MINIMUM 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />SIGNED TITLE C-9 0/?; .4"*.(464 DATE Z5-2 <br />- aAN