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WELL/PUMP PERMIT <br />SAM JOAa� E vvto� mgfTAL HmTN DerART�68 <br />rT 16 EAST HAzETont AvENuE - STxKToN CA 95296 - (209) 460.1420 <br />NON -REQ E PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />Joe A.M.NUM) C.,mp ZO <br />�_2CosEAPN20G-010- V PAMCHS@• LAND <br />USE APPLIcAfloM * j <br />OWNER NAME 'GV P'M. 531 - 1 85 I <br />OwwRAmmes IIAVV( I ice% C.ISTATFZ. '7 Y0� jqj3t0 to �}7 <br />CON,RACTOR IQ1 Yl G PNOI�Z2 • 1 L V <br />CONTRACTOR ADOREse I 1 I PIC r CrrrISTATE¢r <br />SUBCONTRACTOR PMOW <br />SUBCONfMACTOR ADDRESS CTW TATE" <br />LimsE X C-57 0 C-61 0 D-09 0 Other NUMER V %L -QM LY EXPIRATION DATE V 1 '</V ' A- <br />DOMEST1c WELL SAW -LM: D General Mineral/Colfform Bacteria (4391) 0 Dibromochloropropane (4392) D Arsenic (4393) <br />1WMMM USE 0 Dortos6dPriv.te IrripatiwvAyriaAaral 0 Industrial 0 Water Quality Monitoring ❑ Sol motion <br />D Public water system <br />I dRarert kom oa . water SpMn NNn Corftd Name or PnaN Number <br />TYPE OF WORM New wen 0 Replacement Wap 0 Well Aiteratm modtliCation 0 011ier <br />was(s) 0 of wens 0 Sop Boring(s) s ur barl - 0 Geotachnirai o a k01I g <br />0 Out -Of -Service Wen 0 Out-0FService Wan Renewal 0 Cross -Connection Repair <br />Drilling Method Mud R iYn O Air RafarY 0 Auger ❑ Cable Tod D Push Point 0 Other <br />Proposed Wait 6-P10 ft Excavation . 2-1 in diameter 0 Open Bottom 0 Gravel Pack/Gravel in diameter <br />0 Conductor Casing In diameter / Conductor nCasing Depth ft <br />Was Casing Diartaler m ThkknesalGaupa/ASTM Schad 0 Steel 0 Plastic 0 Stainless Steel 0 Other <br />Grout 8sel Depth R 0 NOW Cement (941b bsg5.10 gal waled 0 Sand Cement sack mbd7 gal water <br />Bent nke (20% solids) 0 Odner <br />Grout Piaeenw t MstlTod K 0 Free Fag 0 Other 0 Retardant / Accelerator (name) <br />PEDMAL Metalled By 0 Driller 0 Pump Contractor 0 Other <br />0 Cencrats Padsstal ODimsrrlons: Width ft Length ftThick In 0 Christy Box ❑ Stow P)ps <br />lem ❑ Submersible❑ Turbine 000w_ HP Pump Set ft Standurg Water Levelft <br />I WITH HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE SAN <br />JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br />CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATION LAWS. <br />REQUIRED FOR I SPEC O�/N��S\-� OP.LEEASE CALL (209) 953-7697 <br />TntE.WIDT Y1V✓� DATE 10-O, -2,1 <br />Application Accepted By <br />Grout Inspeclion By <br />Pump, ft <br />Soli Boring Inap^0- By <br />COMMENTS��cOd <br />DEPARTMENT USE ONLY <br />r <br />Data <br />Data <br />Dale <br />Date <br />Area q l rx Employee IDSA <br />1 �7 <br />❑ SPECIAL Well Permit <br />❑ WAIVER Received <br />Constructed Well Depth ft <br />®fir13 ?0 <br />h SRO CO <br />N �-' �IV� Y <br />17[143-M Wne / / 1 ' / 32 �a �V az WELL filtow PERHT <br />