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WELL IPUMP PERMIT <br /> UN JOAQUIN Couuw ERTAL HEALTH DEPARTiaNT 1868 EAST HASELTON AVENUE-STOCKTON CA 95205.6232(209)468~1420 <br /> NONREFUNDABLE Pi-RmNr <br /> ^ www.s' ov.or ehd EXPIRES 9 YEAR PRDM DATE ISSUED <br /> JOB ADDRESS t� 1 • ^ //t�r'y��C3 1 Crryfzp <br /> CROSS STREET APN Q d.7-10Q_0� PARCEL SQE UIIS LAND DISE APPLICATION Yr <br /> i tpai <br /> OWNFR NAME PHONE <br /> OvvmR Avolte" 5VA T : IZZ CrTYISTATaIZIP Lt.ttME017 S CA. C%,52ZL <br /> CONTRACTOR vlC�� Vj aLt C�1�141 tA]C1 1tr1C• PHONE <br /> CoNTRACTORADOREss P.=3 iOK AI&Og tg.Un S\e9tA �4�6CrrYISTATEMP. ACr'D_�0'R <br /> SUSCOICTRACTOWCONSULTANTVllikAO .. ._W%CC•AWtb PHONE 1-t0^;138 <br /> SURCONTRAC70;dCONSut.TANT.ADDRESs a� S�-�O�AEV1' CTTYiSTATEIZp QQO��t�F.._�A• qS U� _ <br /> LICENSE .KC;-57C-61 _D-09 C//�ittBr NUMBER E%PIRA'FiON DATE <br /> 84.UN0 PARTY: ER Other- <br /> SUBCOWMACTOWCONS110ANT <br /> DOMESTIC WF LLL SAAAPLING:=General Mineral/Coliform HBcteria(4391)-.Dibromochlotopn*ane(4392) _ Arsenic(4393) <br /> FNTENocety c DornesticfPrivate mgaboNAgrimItural . Industrial --WatarQuality Monitortrig Soi3Sampfir4Cnaraetantation <br /> -Public water System <br /> It r men!lrmrf t7, r. Water syiol m Nares Contact Name or Pnene Nit"wr <br /> P WOR .Nees well Replacement Well Well Alterationimodification _ Other <br /> Monitoring Well(s) #of wells SWI 9oring(s) 9o MIMS -Geotechnical <br /> Out-OfSevice Well Out-Of-Service Well Renewal Cross-Carmcction Repair <br /> New Pump Pump Re Iacernattt Pump Repair Raise Well Casi <br /> WELLCON I <br /> Drilling Method Mud Rotary _Air Rolary -Auger Cable Tool Push Point Other <br /> Proposad Wott Depth�ft Excavation_ _in jiarwer Open Bettem ravel PacklGraval Size Nk k4 in Oiamefer <br /> _ <br /> Conductor Gasing,w„(, a�in iometer 1 Conoudor Casing Depin R <br /> Well Casing Diameter_LCL in ThicknesslGaugOASTM Sehed Steel _PlastiC Stahstess Steel Other <br /> Grout Seat Depth n R __ Neat Gement(94 lb b82/5-10 gat seater) _Sand Cernert sack mW7 gat water <br /> XBentonite(20%solids) Other ff <br /> Grout Placement Method Pumpcel KFree Fall .Other Retardant;Accelerator(name) <br /> PEDESTAL Installed By Driller ump Contractor Other <br /> -Concrete Pedestal_11imanSIOrIS:Width 11 L th ft Th ck in -Christy Boz _Stove Pipe <br /> PUMP Subrrivmbie Turbine "Other HP Pump Set R Standing Water Levelft <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 ACTWE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AAA IN COMPLIANCE WITH ALL. <br /> WORKERS COMPENSATION LAWS. <br /> MINIMUM 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL.(269)953-7697 <br /> SWARD TrrLE DATE <br /> b T <br /> AH <br /> 7_777 <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date Area -mpiayee ID# <br /> Grout Inspection By Date _ SPECIAL Well Permit <br /> Pump Inspection 9y Date WAIVER Received <br /> Soil Boring Inspection By Dent Constructed Well Depth ft <br /> COMMENTS <br /> PE SG Ra elvad Glta"w Amount Data PWMW Invoieo X Welt ID# <br /> Cods 11110 By Gash ROMMId SeTviw Re neat <br /> Ifo ��ita 90 ZI3a IZA 1 'UJ <br /> EUD3.'tfle 6"tL23tq HELL 1PUAtP PERNrr <br />