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r <br /> WELUPUMP PERMIT <br /> SAN JOAQUIN COUNTY ENvmoNmPTTAL HEALTH DEPARTMENr IRES EAST HAZELToN AvENUE-STocKroN CA 45205 X232(209)4E8-3420 <br /> NON-REFUNDABLE PERMIT CC _ 1wwlwsjjgov.org/ehd J�EXPIRES 1 YEAR FROM DATE ISSUED <br /> LA <br /> JOBAODRESs t- G' L'' ISL UZ�1� /5i� CrtrrLr /1i/'r)i, lS.�lH�n ia <br /> �1 ) t� n <br /> CROSS STREET y rrO I ra rl f'A�PN 1) S J:)tr( PARCEL S1Zt • 16� ut®u5E APPU4CAT1o�N�f�/jM/�� �o <br /> OWNER NAME kil•G L L/ <br /> /ynn`` a/.�� __P% <br /> ]PHONE t-W <br /> OWNER ADORESI3 VdX I CrTY/STATF0P r11 P.)rX'e <br /> � 1 -� <br /> cONTFLACTOR _� 11�.�� Ptt�1 <br /> CONTRACTORADORLss .., ��� GYrY/STATEfZro -(L') <br /> SUBCONTRACTOR/CONSULTANT _ PHONE t <br /> SUBCONTRACTOR/CONSULTANT ADDRESS CITYISIATE/ZIP <br /> n <br /> LlcensE �G57 G�i1 =D-09 r]Cntler NuMeER�Or'/��`,� E7CPIRATIONDATE <br /> BILLING PARTY: 7 OWNat D CONTRACTOR .`SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING_U General Mineral/CotifOmi Bacteria(4391)a Dibromochlompropane(4392)U Arsenic(4393) _ <br /> rjHDMJIUSE r'.DomesfidPrivate 71 Irrigation/Agricultural F Industrial ❑Water Quality Monitoring D Sal Sampling/Cheracteri2mbon <br /> Fl Public Water System <br /> N�rnenl rrorrl Owner: W alar System Nares C IA0 NemA a Pf—NurtiLm <br /> TYPE OF WORK 11 New Well I Replacement Well Well Akeration/Modir"tion Other <br /> I I Monitoring Well(s) 4 of wells Soil Borings) Not boddgs t Geotechnical it orl-­ <br /> I I Out-Of-Service Well Oul-0f-- ry oe Well Renewal 1 CrOSS-Connect] Repair <br /> I!New Trip Replacement Pump Repair Raise Well C <br /> WFI 1.CONSTRUCTION <br /> Drilling Method 1:Mud Rotary i Air Rotary I Auger ' Cable Incl Push Paint 1 1 Other <br /> Proposed Well Depth ft Excavation in diameter --Open Bottom C.Gravel PacwGravd Size in diameter <br /> E Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched _Steel C Plastic Stainless Steel =Odrer <br /> Groat Seal Depth ft -Neat Cement(94/b baglF6 10 gal water) n Sand Cement __5110 MW7 gal ureter <br /> t I Bentonite(20%solids) Other <br /> Grout Placement Method _Pumped Frce Fall --Other C Retardant I Accelerator(narne) <br /> PEDESTAL Installed By ❑Driller E Pump Contractor - Other _ - <br /> I i Concrete Pedestal Dimensions.Width ft Length ftThick in I Christy Box I Sbove Pipe <br /> PUMP - utunersibieC Turbine E Other _ HP_ ,� PUMP Set /00—ft Standing WaterLeltel_., _ft <br /> i HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SMJOAOu1N COUNTY ORDINANCES. STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WTI" THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> /f NIMUM R ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)553-7697 <br /> 7 <br /> SIGNED t_ z!}r.✓ U TITLE l/Ili') flk t.� DATE ZZL6-- <br /> - IPA��EN <br /> � �VEp <br /> - - _ 44f <br /> - Oq Q(l) <br /> N H o pAR ro L <br /> MFN7 <br /> DEPARTMENT USE -Y <br /> Application Accepted By I %=�L Date 1 RE I Area r �f�^ Employee IDR <br /> Grout Inspection ByDate n rJ SPECIAL Well Permit <br /> Pump Inspection By pp&A��Cf_8 lX1/�.i ar.1+101 Date ❑ WAIVER Received <br /> Soil Boring Inspection By Dale Constructed Well Depth ft <br /> COMMENTS <br /> Pt SC Reor.Ned Chocldtl Amount - Permit! <br /> Codes info B Gash Remitted Date ¢ Invoice R Well IDN <br /> EM043 WIIIZD19 WLLL(PUMP PERMIT <br />