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WELL/PUMP PERM/ <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />NON-REFUNDABLE PERMIT <br />3VVin CALL (209) 953-7697 FOR INSPECTIONS <br />EXPIRES "I YEAR FROM DATE ISSUED <br />JOB ADDRESS $41.2 <br />t. 0ac,4142n_ a (—NNyh 0 <br />N:ltl!_i)IER) CITYIZIP lqUAjvl r�D, q 5 l� o <br />CROSS STREET L1,6%G K IGL1. <br />A/PI'yj / 2I QJ.��,/ <br />)S <br />PARCEL SIZE <br />LAND USE APPLICATION III <br />OWNER NAME <br />L�QU/V �7 <br />j /) <br />PHONE 26q- q49 - 3420 <br />^Sfnik) c:roA42011) <br />OWNER ADDRESS �, ,2.2 G, <br />V � (alta 01A <br />-S <br />� QJ[X wLj <br />CONTRACTOR '64p, 'E��%- <br />/ � <br />60aggKiotj L�0"irwi, <br />Co.ITYISTATEIZIP <br />C <br />PHONE Sjo-�]f7 �C <br />CONTRACTOR ADDRESS .(stmt <br />3 f�MMEACic PILI e <br />CITYISTATEIZIP <br />��)� <br />��iR� C4 ` qS <br />SUBCONTRACTOR (9 QE 46 <br />rG� <br />0IC1L.L'AJg £ / isOM9 <br />921- 3�3-- 10ye'7 <br />SUBCONTRACTOR ADDRESS 9E <br />No we Qn <br />�wPHONE <br />CITY/STATE/ZIP/' <br />_ <br />{I RTI 41 q'/ B-7 <br />LICENSE 0 C-57 D C-61 <br />G D-09 D Other <br />NUMBER ids i65 <br />EXPIRATION DATE 01/19 <br />GEOGRAPHICAL INFORMATION: Coordinates X Y Township J4N RangeljF Section. / <br />INTENDED USE D Domestic/Private D Irrigation/Agricultural ■ Industrial ❑ Water Quality Monitoring D Soil Sampling/Characterization <br />D Public Water System <br />If different from Owner, water tiystem Name Uont= Name or Hnone Number <br />TYPE OF WORK ■ New Well D Replacement Well C Well Alteration/Modification ■ Other CATHfIf4010/G <br />D MonitoringWell(s) 4 o wells C SoilBoring(s) 4ofborings D Geotechnical nofborings <br />C Out -Of -Service Well C Out -Of -Service Well Renewal C Cross -Connection Repair <br />Drilling Method , Mud Rotary D Air Rotary C Auger C Cable Tool G Push Point C Other <br />Proposed Well Depth 200 ft Excavation _0 in diameter C Open Bottom D Gravel Pack/Gravel Size in diameter <br />C Conductor Casing in diameter / Conductor Casing Depth It <br />Well Casing Diameter_ IIckness/Gauge/ASTM Schad C Steel C Plastic O Stainless Steel D Other <br />Grout Seal Depth Neat Cement (94 lb bag/5-10 gal water) D Sand Cement sack mix/`7 gal water <br />C. Bentonite (200 so ids) D Other <br />Grout Placement Method jV Pumped G Free Fall G Other C Retardant / Accelerator (name) <br />PEDESTAL Installed By D Driller ❑ Pump Contractor Other <br />_r. Concrete Pedestal DDimensions: Width ft Length It Thick in / Christy Box ❑ Stove Pipe <br />PUMP D SubmersibleC Turbine D Other HP Pump Set ft Standing Water Level It <br />1 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. 1 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 />MINIMUM 24 HOUR ADVANCE TICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />SIGNED f2tii2G TITLES, IP 2uo!ro12 DATE <br />D TM ENT U E NLY <br />Application Accepted By to <br />Grout Inspection B Data <br />Pump Inspection B Date <br />Soil Boring Inspection By <br />Date <br />Area Employee 0#1154.ZefV u <br />❑ SPECIAL Well Permit <br />❑ WAIVER Received <br />Constructed Well Depth <br />I _ 1 I "- "-' I -"--'-... I : I Date I .' - "' . ,. 1 Invoice # I Well ID# — I <br />d <br />EHD 43-06 <br />4/30112 <br />WELL /PUMP PERMIT <br />