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WELL/PUMP PERMIT Z�,6 ��sb,oK JOa l'4r:000NTY ENVIRONMENTAL HEALTH DEPARTMENT 600 EAST MAIN STREET-$ oN CA 952 2 - (209)468-3420 <br /> NO11 S REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> S <br /> N <br /> JOBADDRE S ,3 > lil! C1�L/�\ � �/l CITY/ZIP Tr"c'CL I C(' C,s-��� a <br /> / /, _ (� o <br /> CROSS STREET I C y�j J1')Gj t� APN �.� �_� .�(� / PARCEL SIZE _LAND USE APPLICATION# (�� (� I D tl m <br /> N <br /> OWNER NAME 1-'ci,Y m Z"C1 07 Uj tr 12je'7'f A 1. L PHONE <br /> OWNER ADDRESS / 6�- _('� � PL <br /> CITY/STATE/ZIP (h70 ,�,•f4 y _� <br /> CONTRACTOR r C (nI.'L M ISL/Q1� I T J // rI + 'PHONES-36 �1�7�r�[1 6 t <br /> CONTRACTOR ADDRESS j a.r Y L 1 �7 Cit CITY/STATE/ZIP //t Gt / r`7 t 1 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS / /// CITY/STATE/ZIP <br /> LICENSE OC-57 :e-C-61 ❑ D-09 Other NUMBER EXPIRATION DATE _3Q •-� <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE ❑ Domestic/Private VIrrigation/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 ❑ Replacement Well C Well Alteration/Modification J Other <br /> " Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings Geotechnical #of borings <br /> ❑ Out-Of-Service Well I Out-Of-Service Well Renewal 1 Cross-Connection Repair <br /> E New Pump ❑ Pump Replacement - Pump Repair <br /> WELL CONSTRUCTION n <br /> Drilling Method &Mud Rot e❑ Air Rotary Auger C Cable Tool ❑ Push Point ❑ Other "qc)2�a/`2 <br /> G <br /> Proposed Well Depthft Excavation " in diameter Open Bottom (Gravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter /.in Thickness/Gauge/ASTM Sched 4 Steel Plastic - Stainless Steel - Othgr <br /> Grout Seal Depth-_dt0'--2 sir ft Neat Cement(94 lb bag/5-10 gal water) $ Sand Cement sack•mix/7 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method APumped C Free Fall ❑ Other C Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller APump Contractor ❑ Other <br /> 11Concrete Pedestal Dimensions:Width ft Length ft Thick in Christy Box - Stove Pipe <br /> PUMP ❑ Submersible[] Turbine ❑ Other HP Pump Set ft Standing Water Level Lmi <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 /> ` MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> SIGNED T c.� _ TITLE F� DATE <br /> EL <br /> NZ <br /> PROPOSED(N)WELL <br /> WELL o HOUSE <br /> OUTBUILDING ❑ PUMP STATION <br /> OUTBUILDING \ \ <br /> SEPTIC Uj ` f P <br /> AY <br /> % EZE <br /> W. <br /> 228 S.I.D. <br /> —— — — — — — N DA UiN <br /> SCHULTE ROAD <br /> 1111 -FI 4f <br /> --- - --- - <br /> DEPARTMENT USE 0NLrYY <br /> J Area Employee ID# �5���'`�'C� <br /> Application Accepted By Date <br /> Grout Inspection By -ter. Date 7 ❑ SPECIAL Well Permit <br /> Pump Inspection B Date 0 ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed We I Depth ft <br /> COMMENTS h CO-1 & - t Lx wis �f <br /> Lt�H �w`i�-�!7 �l 0 ; t 7 ylt7` k L✓J �tV o rl��coy� S��v Z Ol7\ - h S i u soh � 9(( L ���—� <br /> PE SC Received (Check#V Amount Permit/ <br /> Codes Info B ash Remitted Date Service Request# Invoice# Well ID# <br /> N38U zWO 5bodg 3�/ " ' -'�;ozo°tSTO3(3Yv2 <br /> . v d ob g Wp003137 2 <br /> EHD 43-06 y /G �'J�S­& i� [7 1-1-e <br /> 2 WELL/PUMP PERMIT <br /> 9/28/07 <br />