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y <br />sANdoAatna,lm rT <br />WELUPUMP PERMIT <br />Nc <br />EN1RRONMENTAL HEALTH DEPARTMENT 11868 EAST NA2ELTOH AVENUE . <br />NON-REFUNDABLE PERMIT CALL 209 953-7cov FOR (NSPECTtON3 CA goon (�09) 468-420 <br />Joe AWReea 1%J �� -51 i / EXPIRES 7 YEAR FROM DATt issul=o <br />CROSR STREET VIN fpr APN- - O O PARCEL SDSD LAND USE A(P�PgUCATpON li (yp <br />OWNER NAME 1 N IIS '201. ?q- Za O^j <br />A <br />PHONE <br />'201. <br />ADDRESS ,A - _ Ni ffo 5 <br />CITY/9TATdL► \Sl.{Yal f1�,1tLTY <br />COWPACTOR Q 1 rl i n Cl PHONE 2Qg 512 .192Z <br />Ilq r� 1P�l�S P-�t - <br />CoNTRAclroR ADDRESS CRY/STATE&D- MOc�P n r I G 53" <br />SUBCONTRACTOR PHONE O <br />Iqult I11 cy& ADDRRU CRYISTTAmTE7P <br />IILICENSE XC -57 0 C-61 D ✓ VnD-W D Other NUMBER 2-Y E)UnRATION DATE <br />DOMESTIC WELL PUNO: ❑ General Mineral/Coliform Bacteria (4391) O Dibromochloropropene (4392) O Arsenic (4393) <br />1NTEHDED Use�%brk <br />gatlorJAgricultural ❑ Indu&trial D Water Quality Monitoring ❑Soil Sampling/Chsracterizatlon <br />Conlan Nam& a Phon& NumberW.t&r sy.tsm rtsn,a <br />T`JPE Of WORK': .0 New. WellReplacement Well 0 Well Atteration /Modificallon & d Cher • d Wring.'0 Monitoring Well(&) * of wells 0 Sol Boring(s) 0 GeWechnlcal <br />0:Ou1-Of-Servxx Well 0 Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />m D....... D.—Ir 0 Raise Well Casing -- <br />tlllnp Method )(1Aud�Rot�ar(y� ❑ Air Rotary 0 Auger jam]❑I Cable Tool ❑ Push Point ❑ Other <br />oposed Will Depth_LR It Excavation �= in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel Size in diameter <br />❑ Conducto Casing In diameter / Conductor ing Depth R <br />Well Caning Diameter in ThicknsaslGeuge/ASTM Schad ❑ Steel Plastic 0 Stainless Steel 0 Other <br />Grout Seal Depth R ❑ Neat Cement (94 Ib bag(S10 get wafer) Send Cement sock murl7 gal water <br />XBentonite (20% solids) 0 Other <br />-... Dr..........r Y.,hm 4.Pumr d 0 Free Fall 0 Other - 0 Retardant / Accelerator (name) <br />n <br />By D Driller ❑ Pump Contractor❑ Other <br />rte Pedestal ODimenslons: Width I Length R Thick In 0 Christy Box 0 Stave Plpe <br />0 SUbmersibI*0 Turbine O Other HP Pump Set n aurnamg vYa.v, �..o. <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. 1 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 />.un .oe rnMPFN3ATION LAWS. <br />S <br />VNT <br />�D <br />'OZ1 <br />p TMENT U E ONLY <br />*N&0A <br />Application Accepted By 4 "- Date �y Area i Employee IDM <br />Grout Inspection By Data ❑ SPECIAL W@II Permit <br />Pump InspectlortBy Date ❑ WAIVER Received <br />Soll Boring Inspection By Date Constructed Well Depth It <br />COMMENTS <br />Invoice M I Well IDM <br />WELL IPVMP PERMIT <br />