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WELL/PUMP PERMIT <br />EXPIRES 1 YEAR FROM DATE ISSUED <br />4A-Ak f CnY/Zip <br /> aza-cs_ Mht\* <br />CONTRACTOR ADDRESS 145 atiy 7 a <br />SUBCONTRACTOR/CONSULTANT 0 to..41-1Cfr' <br />SUBCONTRACTOR/CONSULTANT ADDRESS <br />6A) Ota <br />) ;-• f-r <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95206 -6232 (209) 468-3420 <br />NON-REFIJI,IDABL PPRIVIIT VI/WW.Sjc3011.orgielid <br />:2- 1.51 <br />a xfx <br />OLP at 124a- 0 -474°-71` <br />APN <br />2_6 <br />91)2 0-3r <br />PHONE 3.3 fr.-- er <br />cmdsTATEiziptv17 <br />CITY/STATE/ZIP <br />LAND USE APPLICATION # <br />PHONE :ss?.aociy aLIS PARCEL SIZE <br />TYPE OF WORK tfeNeW Well IiReplacernent Well rI Well Alteration/Modification i Other <br />I ! Monitoring Well(s)__ #01 wells <br />I I Out-Of-Service Well I I Out-Of-Service Well Renewal LI Cross-Connection Repair <br />)41Sfew Pi imp I I Pump Replacement I Pump Repair 11 Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method >aid Rotary I 1 Air Rotary 1 I Auger ri Cable Tool n Push Point 11 Other <br />Proposed Well Depth_ c_S—CO ft Excavation in diameter 1.1 Open Bottom Ikeravel Pack/Gravel Size .g in diameter <br />LI Conduc r Casing in diameter - / Conductor Casing Depth . ft <br />Well Casing Diametei in Thickness/Gauge/ASTM &Med 220 n Steel ;elastic Li Stainless Steel n Other <br />Grout Seal Depth SIP fl Il Neat Cement (94/b bag/5-10 gal watei) )Sand Cement /Ô .3 sack mix/7 gal water <br />f I Bentonite (20% solids) i'l Other <br />Grout Placement Method yiteumped ,1 Free Fall Li Other I.! Retardant i Accelerator (name) <br />it of borings it of borings II Boring(s) r Geotechnical <br /> 19r 444.6 <br />- <br />' DEp'7,11/ 'v rY <br />'11'04f <br />Area • Employee ID#• <br />PE AL Well Permit <br />WAivER Received <br />Constructed Well Depth ft <br />to <br />rn <br />Permit/ • <br />Service Request 4 Invoice It Well 11)4 <br />(A/PW.Y11 <br />WOOL1-0-,W--- <br />WELL /PUMP PERMIT <br />LICENSE ,j,)14,57 r 9-09 LI Other <br />NUMBER 27 7 3g-f EXPIRATION DATE <br />BILLING PARTY: ' OWNER CONTRACTOR SUBCONTRACTOR/CONSULTANT <br />DOMESTIC WELL WELL SAMPLING: ' General Mineral/Coliform Bacteria (4391) • DibrOmochloropropane (4392) Arsenic (4393) <br />li\rril\pEo UsE Domeslic/Privato 6417ri7ation/Agricultural II Industrial I I Water Quality Monitoring I 'Soil !--.3ampling/Chairacterization <br />Public Water System <br />If different from Owner: woier systnin Name Contact Name or Phone Number <br />JOB ADDRESS <br />CROSS STREET <br />OWNER NAME <br />OWNER ADDRESS <br />CONTRACTOR <br />PHONE <br />CITY/STATE/ZIP <br />Application Accepted Ii <br />Grout Inspection By <br />Ptintp Inspection By <br />Soil Boring Inspection By <br />..:OMMENTS <br />51111,70 Il <br />/4. TMENT USE ONLY <br />ate / <br />Date .161 <br />Date 5/1111i4 <br />Date <br />SC Received Check#/ <br />Ira° By Cacti <br />Amount <br />iemittod _