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WELL/PUMP PERMIT <br /> SAN JoAoutH Couim ENVIRONMENTAL HEALTH DEPART1aENT 1666 EAST HAZELTON AVENUE-STOCKTON CA 96206-(209)466-3420 <br /> NON-REFUNDABLE PERMITCALLCALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE(ISSUED <br /> Joe ADOREes 4 Cm/LP tS Galo N, (A -1✓,�f fav � <br /> nt/ ZM-2o0-320 <br /> CROSS STREET APN PARCEL 812EI.AND USE APPLICATION 9 <br /> OWNER NAME M Ivy PHONE -1✓ V <br /> OWNER ADDRESS 2A\Q\PU Ma CITY/STATEMP f9101114' IM <br /> CONTRACTORMaStifiS I PHONE 2.0q/'/5z2-I q Zt <br /> CONTRACTOR ADDRESSIN I r CRY/STATEZ1P M 0 dQJ'1 D. 6 q5397 <br /> /7 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS Cm//ST�AATTEIZIP <br /> LICENSE G57 0 C-81 0 D-09 0 Othau NUM9ER UU Y V LXX ExrotAnoN DATE r f <br /> DOMESTIC WELL SAMPIl General Mineral/Coliform Bacteria(4391)QT Dibromochloropropane(4392)❑Arsenic(4393) <br /> INTENDED USE Domesbc/Privste 0 Irrigation/Agricultural 0 Industrial 0 Water Quality Monitoring 0 Soil Sampling/Characterization <br /> Pudic Water System <br /> It dlRarara rmm Ow Water System Name Contact Name or Phone Number <br /> TYPE OF WORK 0 New Well Replacement Well 0 Well Atteration/Modification 0 Other <br /> 0 Monitoring Wel(s) N of wells 0 Soil Boring(s) s of borNs 0 Geotechnical s or borings <br /> 0 Out-Of-Service We" 0 OW-Of-Service Well Renewal ❑Cross-Connection Repair <br /> 0 New Pump 0 Pump Replacement 0 Pump Repair 0 Raise Well Casing <br /> Drilling Method ud0 Air Rotary 0 Auger 0 Cade Tool 0 Push Point 0 Other <br /> Proposed Wali 1�I' <br /> Depth Rota R Excavation s!�_in diameter 0 Open Bottom I,XGravel Peck/Gravel Siz <br /> 0 Conductor Casingin diameter <br /> in diameter / Conduc rKCasfng Depth R <br /> Well Casing Diameter in Thickness/Gauge/ASTM Schad v?� ❑Steel Plastic ❑Stainless SlaeI 0 Other <br /> Grout Seal Depth ft 0 Neat Cement(94 Ib bagib 10 gal water) 0 Send Cement <br /> 'Bentonite(20%solids) 0 Other -sack mlXn gal water <br /> Grout Placement Method umped 0 Free Fall 0 Other <br /> 0 Retardant/Accelerator(name) <br /> PEDESTAL, Installed By 0 Driller 0 Pump Contractor ❑ Other <br /> o Concrets Pedestal ODlmonelons:WK" ft Length R Thick <br /> in 0 Christy Box 0 Stow Pipe <br /> MP 0 Submersible❑Turbine 0 Other HP <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION ANPump Set it Standing Water Level ft <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA COD RULES AND REGULATIONS, I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> WORKERS COMPENSATION LAWS. <br /> CURRENTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> SIGNED <br /> MINIMUM 48 HOUR ADVANCE NOTICE REQUIRED FOR IN PECT�oNS-PLEASE CALL(209)953-7697 <br /> TrTLE 11 1 DhlNfiV <br /> DATE <br /> 13 <br /> N <br /> DEPARTMENT USE ONLY <br /> Application <br /> Accepted By L L_ <br /> DateC� <br /> Grout Inspecbon B Area Employee 10# /`,I <br /> Pump Inspection By to 0 SPECIAL Well Permit <br /> Soil Bori spection By Dela 0 WAIVER Received <br /> COMMENTS Date Conrtructed Wall Depth <br /> R <br /> PE SC Received Check!! 11 <br /> Codes InfoAmount <br /> B PermW <br /> Caah Ramttted Date 4 Liao Service R usst S, Invoice S Well IDS <br /> PO L <br /> EH043-W movie <br /> WELL&UMP PERMIT <br />