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%t ` WELL/PUMP PERMIT <br />I SAN JOAom Couam ENvinosinIB(rAL HEALTH DEPARTmBrT 1969 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 488-3420 <br />N-KEFUNDABLE PERIIITT <br />CALL 209 953-7597 FOR INSPECTIONS <br />EXPIRES 1 YEAR FROM DATE ISSUED <br />ADDRESS %1116 <br />N . „� <br />,,,�, <br />cnyizp54o� <br />r'k 9 <br />S3 STREET <br />APH d1 b2JD- OLID <br />PARCEL SIM /'-" <br />LAW USE APPuCATION # <br />MER NAv <br />ME �' � <br />^I' 4:>b r,&r0 <br />Pw. qo l - 9-7914 <br />ERADDRESS i�'i b <br />N. MUM <br />Rd <br />cffy umr(1P <br />k/N r G .e S73k <br />TRACTOR_Mwsrcllit <br />Dn�IIIN1 <br />:7�r <br />P"M 522-- 142D <br />TRACTOR Amrxu .. l iw\ <br />A ly <br />Q -k• <br />C1111STATE2. <br />M Q J414, Lw 4535 <br />PHONE <br />CmiSTATE1Zm <br />C57 0 C-61 0 D-09 0 Ober NUMBER ('L ra(m LG ExPIRATM <br />Doomm WELL SAMPLM A General Mirmul/Coliforrn Bacteria (4391 jX Dlbromochloropropene (4392) 0 Arsenic (4393) <br />INTt7Iow USE Darodaprivaw 0 invatiorNAgriculbaal 0 Industrial 0 Water Quality Mudtoft 0 Sal Sampling/Characterization <br />0 Public Water System _ <br />xAeawe can OMW water system N m Canted Narro or Phare Number <br />TYPE OF WORN `II( New well *eplacement Weil D Well AneratkWModilicauwt ❑ Other <br />0 Monitoring WeRs) # of wells 0 Sal Swing(s) s of bminp 0 Geotechnical 0 d baiga <br />❑ Out-Ol-Service Well ❑ Out-OfSenriee Well Renewal ❑ Cross -Connection Repair <br />Katie Well <br />Drilling Method ;K Mud Rotary D Air Rotary 0 Auger 0 Cable Tool 0 Push Point 0 Other <br />Proposed Well Depth it Excav M. � in diameter 0 Open Bottom V Gravel P.WGnavel Siz le diameta <br />❑ Conductor Casing in dlameter / Conductor Casing Depth 9 <br />Well Casing Diameter _J._ in Thiduess/Gauge/ASTM Schad 7-6y ❑ Steel (Plastic 0 Stainless Steel 0 Other <br />Grout Seat Depth /O r7 R 0 Neat Cement (94 Ib bap/6.10 gel water) 0 Sand Cement sack mizf7 gal water <br />0(Bsntonke(20% solids) 0 Other <br />Grout Placement Method li Pumped 0 Free Fail 0 Other 0 Retardant /Accelerator (name) <br />PETAL Installed By ❑ DOW Contractor 0 Other <br />0 Concrete Pedestal ODinwnsbns: Width it Length R Thick In 0 Chday Box ❑ Stove Pipe <br />u 0 Submersible0 Turbine 0 Otter HP Pump Set it Standing Water Level it <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. I 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 />WORKERS COMPENSATION LAWS. <br />t�IrIM 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209))953-7697 <br />SIGNED Tm.E 01.-1. f/ • <br />DATE Cy -s'-21 <br />/ DEPARTMENT USE ONLY <br />Application Accepted By — r� Date / Z �% Area 1 �^ Employee IDA Fr,'• g'I' r'` <br />Grout Inspection By Data ❑ SPECIAL Well Permit <br />Pump Inspection By _ . _.. Deet ❑ WAIVER Received <br />Sail Borkg Inspection ByDate- Constructed Well Depth It <br />a? <br />COMMENTS /' i�irh� ►-1 <br />VT <br />aI <br />WA <br />