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WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 EAST MAIN STREET -,i fOCKTON CA 95202 - (209) 468-3420 <br />DI VIY-Rtt'UNUAtfLt rtKMI l %,/ALL [UJ U3J-r0V f FOR INSNECI IONS <br />CArIKCJ T TEAR FROM DATE ISSUED <br />JOBADDRESS <br />� W Crr 0.(\i `,\ ne Qd <br />• CRV/zlpr <br />ac,v . C A 06 374 b <br />d0dARCEL 'Y3 <br />CROSS STREET <br />� ` � APN �] D <br />SIZE <br />LAND USE APPLICATION #�1 <br />OWNER NAME <br />�` <br />M e - ) J 0`O`A <br />n 1 <br />PHONE t - lOct' JJ'•'y3, 114 <br />OWNER ADDRESS <br />C�C3. <br />.J �l///'III w' V t aClt `t e Q <br />(U� <br />a CITY/STATEIZIP I (- lu, cl 1 <br />C RUcp I <br />k <br />CONTRACTOR <br />�/ n C , <br />r <br />CONTRACTOR ADDRESS 54 • O U C C Q Q <br />L C CITY/STATE/ZIP <br />CP/H�O/N�E�� <br />^ <br />.J VX `� M Q 3 lJ� <br />S 0� <br />SUBCONTRACTOR <br />PHONE <br />SUBCONTRACTOR ADDRESS 'bo <br />� Lel `C�ITY/SSTAT�E/Z/IP <br />LICENSE C-57 ;!f4--61;!f4--61F1D-09 I Other NUMBER VO p EXPIRATION <br />GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section_ <br />INTENDED USE ❑ Domesfic/Private i Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization <br />❑ Public Water System <br />If different from Owner: Water System Name Contact -Name or Phone Number <br />TYPE OF WORK ❑ New Well Ll Replacement Well I Well Alteration/Modification (.Other 01'M'l 1-1,406es. <br />❑ Monitoring Well(s) # of wells n Soil Boring(s) # of borings U Geotechnical # of borings <br />❑ Out -Of -Service Well I I Out -Of -Service Well Renewal Cross -Connection Repair <br />I I New Pump ❑ Pump Replacement (I Pump Reoair i I Raise Well Casino <br />Drilling Method IJ Mud Rotary El Air Rotary ❑Auger IT Cable Tool ❑Push Point -K Other <br />puL' JA"OOK Imr- <br />Proposed Well Depth It Excavation in diameter n Open Bottom I Gravel Pack/Gravel Size in diameter <br />n Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter I in Thickness/Gauge/ASTM Schad i i Steel i i Plastic i Stainless Steel I I Other <br />Grout Seal Depth ft Neat Cement (941b bag/S-10 gal water) Sand Cement sack mix(7 gal water <br />I Bentonite (20% solids) Other <br />Grout Placement Method I I Pumped Free Fall CI Other ❑ Retardant / Accelerator (name) <br />PEDESTAL Installed By I I Driller I I Pump Contractor ❑ Other <br />I Concrete Pedestal Dimensions: Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe <br />PUMP I Submersibleu Turbine Other HP Pump Set ft Standing Water Level ft <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 ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATION LAWS. <br />SIGNED <br />Application Accepted By <br />Grout Inspection By <br />Pump Inspection By <br />Soil Boring Inspection By <br />COMMENTS <br />DEPARTMENT U E ONLY <br />Date S �� <br />Date <br />Date <br />Date <br />DAT <br />N� <br />Area �Employee ID# <br />SPECIAL Well Permit <br />WAIVER Received <br />1 r <br />vl <br />-Y <br />A <br />J) <br />04 <br />I I I 2A/ <br />T04wi Xq <br />Constructed Well Depth It <br />PE SC Received <br />Codes Info B Cash <br />Amount Date Permit/ Invoice # Well ID# <br />Remitted Service Re uest # <br />AMS 3M 22ei S$ -7 3 <br />4127 32(l ',P00 ('q(p0- <br />EHD 43-06 <br />8104108 <br />WELL /PUMP PERMIT <br />