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1 WELUPUMP PERMIT <br /> SAKI Jowouai CouNTY EKARONNENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STocKTON CA 95205 -(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> Crr <br /> JOB ADoRE88 L")Olftwnd 94 Y2PHantf T l 153_ <br /> CROSS STREET pN PARCELSIZE 1 .6 LAND USE APPLICATION# <br /> PHONE M_ <br /> AP <br /> OWNER NE <br /> OWNER ADDRESS ,Sbj Ah CRYISTATEIZP H U 1//��� CA I JAI/ <br /> CONTRAC" I0 Orillina PNONE 20 j-cj2 Z-- 1192E <br /> CONTRACTOR ADDRESS CHY/STATEIZP <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CFTP <br /> C- Y/STATEIZ <br /> LicENSE ! 11Cm-61D-09 Other NumwR W LQ Z Z EMRAim DATE 913C)12-5 <br /> DOMESTIC WELL SAMPLMG:XGeneral Mirmral/Coliform Bacteria(4391) _ Dibromochbropropane(4392) Arsenic(4393) A <br /> wig UsE KDomestidPrivate 0 lmgatioNA®mLftUral U Industrial ❑Water Ouaky Monitoring ❑Soil Sampling/Charact <br /> 0 Pubffc Water System CE/I T <br /> K ciRerent from Owner. Water System Narne Contact Name or Phone Number <br /> TYPE OF wows XNew Well 0 Replacement Well 0 Well Afteratlon/Modification ❑ Other <br /> ❑ Monitoring Weil(s) #of wells 0 Soil 1 OHN(S) #°f berm 0 Geotechnical <br /> a e[Well Rent U Pura R�ce Well Renewal ❑ Raise <br /> Repair ' 774, �� N �CCUN <br /> New Pu <br /> WELL CONSTRUCTION <br /> Drilling Method K Mud Rotary 0 Air Rotary 0 Auger 0 Cable Tool ❑ Push Point ❑ Other <br /> Proposed Wall Oepth_ 21?bo ft Excavation " in diameter ❑ Open Bottom Kr--ravel PaddGravel Size in diameter <br /> U Conductor Casing in diameter / Conductor Casing Depthft <br /> Well Casing Diameter�in Thk;lmess/Gauge/ASTM Shed O ❑ St— Plastic 0 Stainless Steel ❑ Other <br /> Grout Seal Depth _ft ❑ Neat Cement(94 tb bay5-10 gaf water) and Cement _sack mar/7 gal water <br /> ntonfte(20%solids) 0 Other <br /> Grout Placern Method XPumped ❑ Free Fall ❑ Other ❑ Retardant/Accelerator(name) <br /> PWUTAL Installed By 0 Driller 0 Pump Contractor ❑ Other <br /> ❑Concrete Pedestal ODirrrensloos:Width ft Length It Thick <br /> lin ❑ Christy Box ❑ Stove Pipe <br /> PUMP ❑ Submersible❑ Turbine u Other HP Pump Set ft Standing Water Leve} ft <br /> Plot Plan Requirements: Attach a plot plan with the exact location of water well with respect to the following items: GPS <br /> Coordinates, property lines, adjoining properties, water bodies or courses, drainage pattern, roads, existing wdK structures, <br /> potential sources of contamination, sewers or private disposal systems. Include distance from two property lines.For Domestic, <br /> Agriculture,Industrial well,provide location of any water wells or surface water within 200'radius of proposed well. <br /> MINIMUM 7,4 HOUR ADVANCE[NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL.(209)953-7697 <br /> DEPARTMENT 7E/�NLYApplication Accepted By Date <br /> Z Area <br /> ! Employee ID# C <br /> Grout Inspection By Date tJ 1\��1� 0 SPECIAL Well Permit <br /> Pump Inspection By Date LI WAIVER Received <br /> Soil nspBdiorl t3y Dere Constructed Well Deptfi tt <br /> COMMENTS <br /> PE Sc Received Checkillf <br /> lServi <br /> Amount Daft ce� 0 Invoice# Well IDS <br /> Codes Info <br /> ZO ; WF0043'9607 <br /> qgql 1,557 <br /> 939 Z2- <br /> 597.00 <br /> 0TD013A60rr0TrJM PW 1 ort WeD Pump Pani <br />