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T _ <br /> SAHJoAauwCouNrrE WE1L/PUMP PERMIT <br /> NVNtONMENTAL HEALTH DEPARTMENT 1888 EAST HAZELTON AVENUE <br /> NON-REFUNDABLE-PERMIT CALL 209 953-7697 FOR INSPECTIONS STOC�OdN CA 11s2os.(2011)488-3420 <br /> JOB ADDRESS 11 j� EXPIRES 1 YEAR FROM DATE ISSUED <br /> CROSS STREET 1`�IN r APN - i2 _-0�}p - `TYAP <br /> /� (�jJ i (� ✓� r\�nPA�RjCEL4$�ifZ�E� V LAND USE API} 4 <br /> P�LICAT1ON fl Q <br /> OWNER NAME <br /> OWNER ADDRESS PHONE 2"n�1 V�V �j� & <br /> '1V`1 _ <br /> CDNTRACTOR 1`l U� l' I r, ` I I f J CITY/STATLZP���A 1/!(�A <br /> PHS IA S LZ -19 Z� <br /> CONTRACTOR ADDRESS I1'1 rl t l/VRS f'l/\ CrTY/STATr0'm b rIQI q` —397 <br /> SUBCONTRACTOR PHONE O <br /> I <br /> SI7aL{)N I IlActba ADDRESS CITY(STAppTERIP ]I <br /> ucEHSE V-57 D D WC-61 0 D-09 a Other NUMBER ZL— EXPIRATIONDATE <br /> DOMESTIC WELL SAMPLING.❑General MineraVCoiiform Bacteria(4391)0 Dibromochloroprop ine(4392)0 Arsenic(4393) <br /> INTENDED USE Domestir/Private 0 ImgationlAgricuitural G Industrial 0 Water Quality Monitoring 0 Soil Sampling(Characterization <br /> D PUbk Water System conw Na—or Phone Nom, <br /> H d8rrenl hom Owrrr: WSW System Hame <br /> TYPE OF WORK D New WellReplacement Well D Well Alteration/Modification :l Other A« �� <br /> 0 Monitoring Wells) <br /> #of wells D Soil BOring(s) sp1on". D Geotechnical <br /> r Out-Of-Service Well 0 Out-Of-Service Well Renewal 7 Cross-Connection Repair <br /> 0 New Pum 0 Pump Replacement D Pump Repair O Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method)QMudAir Rotary D Auger 0 Cable Tool D Push Point n Other <br /> Proposed Well Depth Rota _fl Excavation 1Z m diameter D Open Bottom G Gravel Pack/Gravel Siz n diameter <br /> i l Conductor Casing in diameter / Conductor C sing Depth R <br /> Well Casing Diameter 4in .Thickness/Gauge/ASTM Schad _ C Steel Plastic 0 Stainless Steel D Other <br /> Grout Seal Depth 'LOU R 0 Neat Cement(94 Ib bag/5-10 gal water) C Sand Cement sack mixl7 gal water <br /> Bentonite(20%solids) 0 Other <br /> Grout Pincement Method Pumped 0 Free Fall 0 Other 0 Retardant I Accelerator(name) <br /> PEDESTAL installed By D Driller D Pump Contractor 0 Other <br /> 0 Concrsta Pedestal DDlmenalonw Width_11 Length R Thick in 7 Christy Box D Stove Pipe <br /> Mp 0 SubmsrsibleC�Turbine 0 Other HP Pump Sat R Standing Water Level R <br /> 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> ORDINANCES,JOAQUIN COUNTY STATE <br /> CURRENT AND ACTIVE WITH THEFCALIFORNIAORNIA CONTRACTORS STATE LICENSE EN EBAND CERTIFYSO BOARD <br /> THAT I AM N COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. 1 <br /> M�48�H'yyODUDR AID)JANCE REQUIRED FOR I,SPEC IONS-PL SE CALL(209)O� DI �iO�l <br /> MUL7 <br /> SIGNED 'V'�— TITLE Yl DATE <br /> e <br /> ECA/T <br /> --- ---------------I Vj --------2�4�------------------- <br /> ®y �?� <br /> 1 1 -FT-T=E H 14�. <br /> r pgR�oN�y <br /> %iAP�LITMEN&UE ONLY /�Application Accepted By Date0011 Area Employee ID#Grout Inspection By Date �ZI L SPECIAL Well Permit <br /> Pump Inspection By Date G WAIVER Received <br /> Soil Boring Inspection Byy Dale Constructed Well Depth ft <br /> COMMENTS i�✓�lil l 5�4� 0� 20 <br /> PE SC Received Chock#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info h emittedervice R nest i< <br /> 0 .5�- aw '' I' <br /> r <br /> EHD 43-06 8101718 39! Il J WELL(PUMP PERMIT/ / / � <br />