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WELL 1 PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL 14RALTH DEPARTMENT 304 E WEBER AvE Y'FL-STOCtcraN CA 95202-(209)468-3421 <br /> NON-REF WDABLE PERMIT CALL 204 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED v <br /> $ADDRESS (ll CT1'Y2e <br /> `15Z " <br /> ' _ a <br /> CROSS STREET APN D ARCEL SIZE--,L--LAND USE APPLICATION H <br /> �v f <br /> Si le 'Va lL: PHONE <br /> OWNERADDRESS <br /> -1Iwo � CITYISTATEMEP <br /> _ <br /> CONTRACTOR "'I j P�H�ONE{ y� 0 <br /> CoNTRACTORADDRESS 12A- ClTI STAT.IZIP f Y,LLY'T1�+LP 6 L`1 _I �� <br /> �1 <br />€ SUBCONTRACTOR PHONE <br /> SuacoNTRACCOR ADDRESS <br /> LICENSE C-57 0 C-61 ❑D-09 d Other Nluats R A . <br /> GEor-RAPHtCALINFoRMATION: Coordinates X Y Township Rnn e' Section_ <br /> INTENBED USE ❑DomesticlPrivete ❑lmgation/Agricultmal 0]ndustri1 eel• r ty S erizatioD i <br /> ❑Public Water 5 stemL �� <br /> if rfi�t Crum Owner eta yeti Rare r 1 e� <br /> TYPE OF WORK 0 Now Well El Replacement Well ❑Well Alteratiott/Ml7ij�f)catio�sivjljQ f� ole i 4 r�.I <br /> ❑Monitoring We11(s) #of wells 0 Sail Boring(s) 4A'8t 66r�kt Gi.fi l�votec tnical <br /> •Well Destruction D Out-0f--Service Well ❑Out-Of-Sernce Well Renewal <br /> ❑New Pump ❑Pump Rzplacement ❑Pump Repair ❑Cross-Connection Repair �J <br /> WEt.L CONSTRUCTION �F <br /> Drilling Method ❑Mud Rotary 11 Air Rotary - ❑Auger Cable Tool ❑Push Point '�Other i <br /> Prapesed Well Depth 6' ft Excavation in diameter ❑Open Bottom ❑Gravel Pack!Gravel Size n diameter <br /> 0 Conductor Casing in dimneter / Conductor Casing Depth $ <br /> f/��� 11 Steel ❑Plastic ❑Stainless Steel ❑Other ' <br /> Well Casing Dinmeter�r"'yn T!»cicn srGaugelASTM Schad <br /> Grout Seal Depth_S d'(A V il eat Cement(P4 III sag 15-10gaf water) ❑Sand Cement sack mix/7 gal water <br /> K'ufacturer Spec%solids % Name ❑Specs on File ❑Specs Subanitte <br /> Grout Placement Methodped ❑Other ❑Retardant I Accelerator(name) j <br /> PEDESTAL Installed liv ❑Driller ❑Pump Contractor ❑Other <br /> A ❑Concrete Pedestal Dimensions: Width_ft Length_ft Thick in ❑Christy Bas 0 Steve Pipe <br /> POMP 13 Submersible 11Turbine - 13Other HP Pump Set ft Standing Water Level ft <br /> I HERESY CERTIFY TI4AT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONF: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 L_ICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> . WORKERS CON TENSATION LAWS. ` <br /> 7MINLMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR I�NSP/E�CTIONS <br /> STONED7JYlls1=1'—sX11 <br /> a <br /> t --- <br /> i e } ,. <br /> YM1E�'�` <br /> CEIVED <br /> 2044 <br /> -- flUIN COUNTY <br /> ONMENTAL <br /> DEPARTAAENT <br /> n <br /> ARTM-E IVT USE ON 'Y <br /> f[ Application Accepted By ate �J �/ r Area Employee ID#_ y -F <br /> Grout Inspection By Date JJ Q SPWell Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Destruction Inspection By Date Constructed Well Depth ft <br /> CO 5 `� <br /> SC +Received 131 Amount Permitf Invoice ft Well IDN <br /> Info as <br /> Remitted ate Service R nest# <br /> l Codes � <br /> ir <br /> 'A{� •^ P7MPP <br /> &VD4 <br /> EKD43-62-006 <br />