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1 WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENviRowvErrrAL HEALTH DEPARTMENT 1868 EAST HAZFLTON AVENUE-STMKM CAM05 -(208)488-3420 <br /> NOH-REFuNimmx PERMIT CALL 209 9,53-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRIM � Grr/LP <br /> CROs sir j p AM _ jAnM SIDE tffLAND Use APPLICATION it <br /> OWNER NAe>E V v NONE <br /> OWNER ADDRESS ! CITyarATEfIP Obckill-il I <br /> CONTRACTOR PHONE 126 —622�~rI-G►I2 <br /> CONTRACTOR ADDRESS - { CRY/STATE/ZP <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CrTYISTATT:IZIP <br /> LICENSE C-57 0 C-61 ❑ D-09 0 Other NUMBER U zz EXPiRATim DATE <br /> DOMESTIC WELL SmmsiG_L j General Wrief-WC Aform Bacteria(4391)Li Dibrotnochioropropane(4392)-Arsenic(4393) <br /> [KrE DED tls6 Domestic(Pdvate O krigalion/ngricul Li al ❑ Industrial ❑ Water Quafiity Monitoring ❑ Soif Samping/ChaTacteTrza ion <br /> ❑ Water System <br /> 11dearari inn Owrar WaW Syeiern Nana CaKad Name or Phase Nurnber <br /> TYPE W WOw eM Well 0 Replacement well o Well AAaratiaTlModilication ❑ Other <br /> ❑Moniorxing Wel(s) #of Wens U Soil Bm"(S) ` E of bairgs ❑Geotechnical /of bMUga <br /> 0 Out-Of-Service Well ❑ Out-Of-Service Well Renewal 0 Cron;-ConneCtion Repair <br /> ❑ New Pump U Pump RepLacement ❑ Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drlilfrlg MethodXMud Rotary 0 Air Rotary ❑Auger, [�Cable Tool 0 Push Point ❑ Other <br /> Proposed Well Depth___ X ft Excavation _in diameter U Open Bottom ❑ Gravel Pack/Gravel S¢e in diameter <br /> 0 Gond or Casing in diameterConductorft Casing Depth <br /> Well Casing Diameter JrI in ThidmeWGaugeIASTM Sched_= ❑ Steel Plastic 0 Stainless Steel El Other P4YM ENT <br /> Q <br /> Grout Seal Depth _ft ❑ Neat Cement(941b bay5-10 ga/watery ❑ Sand Cement sack mind7 gal at <br /> D Bentonite(20%soids) ❑Other S <br /> pGT04A Placement Method El Pumped ❑ Free Fall 0 Other ❑ Retardant/Accelerator(name) 2�2� <br /> SA <br /> ,+ L budaUd Ely ❑DfilliBf ❑Pump Contractor ❑ OtherENVIRON QTY <br /> 11Concrete Pedestal DDkne�siotts:Width ft Length ft Thick PAR ENT <br /> in ❑ Christy Box ElStow Pipe <br /> PM ❑ S s"e❑ Turbine D Other HP Pump Set ft Standing Water L ft <br /> Plot Plan Requirements: Attach a plot plat with the exact location of water well with respect to the following items: GPS <br /> Coordinates, property 6nes, adjoining properties, water bodies or courses, drainage pattern, roads, existing'i P6 ktY�c , <br /> potential sources of contamination,sewers or private disposal systems.Include distance from two property lines...For Domes c, <br /> Agriculture,Indasbial well,provide location of any water wells or surface water within 200'radius of proposed^Lhtd WIN COUNTY <br /> ONRINTAL <br /> HEALTH DEPARTMENT <br /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> DEPARTMENT USE ONLY <br /> Application Accepted BY Date o� 07 v� Area Employee ID# A <br /> Grout w6pection 13Y l:L �\ to 1�OL'C (.Z D SPECIAL Well Permit <br /> Pump Irispection By Date ❑ WAIVER Received <br /> Sal Bating Inspection ByConstructed Well,Depth ft <br /> COMMENTS be- PS ra CpQfe o r" r_-, . S rte, 'F u m P rl r i <br /> ISE Sc Received chne Ta!! fou Date Permit! Invoice# Well ID# <br /> Codas 600 Rerrdtbd Service # <br /> 70 d .a �A- l•I 2'- <br /> 93 q I fS- <br /> '13�a 7c <br />