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Z <br /> //0/NhCA9521P(Z209)468-3420 <br /> 6 <br /> WELL/PUMP PERMIT J':JOO l',P%COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 EAST MAIN STREET-S <br /> NOi �REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS s Lel I J l Lr� CITY/ZIP T-'ttLl-'1 lD <br /> — <br /> CROSS STREET APN PARCEL SIZE _LAND USE APPLICATION# m <br /> N <br /> OWNER NAME NR Ec,Y yn Z"C1 n 04 "►e-12JeeZ•f J­ L PHONE 5-in - Li —l.)(•, <br /> OWNER ADDRESS �C/� J6��_rl C .(') }" Q CITY/STATE/ZIP ^y(ly/Q/7 ,lam y ^`3 <br /> CONTRACTOR /1/ �i r ( tqO rr L'L M f29 ISI./eT / 1 /T�� 1 'PHONE-`36 -/, 7U -5 o <br /> CONTRACTOR ADDRESS �. l�a C r Vl �7 G( CITY/STATE/ZIP %/(� Gr l�I � Cc, <br /> SUBCONTRACTOR f✓ PHONE <br /> SUBCONTRACTOR ADDRESS /� CITY/STATE/ZIP <br /> LICENSE OC-57 o-C-61 D-09 Other NUMBER Q tj� Y EXPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE � Domestic/Private Irrigation/Agricultural �i Industrial ❑ Water Quality Monitoring 1 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 D Well Alteration/Modification Other <br /> Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings - Geotechnical #of borings <br /> Out-Of-Service Well ❑ Out-Of-Service Well Renewal C Cross-Connection Repair <br /> El New Pump ❑ Pump Replacement 1Pump Repair <br /> WELL CONSTRUCTION n <br /> Drilling Method k1 Mud Ro*�,.w❑ Air Rotary -I Auger -i Cable Tool C Push Point F Other IT // Rd A2 -sem <br /> Proposed Well Depth ft Excavation 14 " in diameter C 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 .f Steel Plastic -: Stainless Steel i: Other <br /> Grout Seal Depth ft G Neat Cement(94/b bag/5-10 gal water) 4( Sand Cement sack•mix/7 gal water <br /> E Bentonite(20%solids) G Other <br /> Grout Placement Method A'Pumped C Free Fall Other C Retardant/Accelerator(name) <br /> PEDESTAL Installed By :-, Driller kPump Contractor - Other <br /> Concrete Pedestal Dimensions:Width ft Length ft Thick in L Christy Box :� Stove Pipe <br /> PUMP := Submersible, 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 /> C MINIMUM 24 HOUR ADVANCE NOTICE REQUIRE/D�FOR INSPECTIONS <br /> SIGNED T�G� � TITLE L� i DATE <br /> �n PROPOSED(N)WELL <br /> WELL o HOUSE <br /> OUTBUILDING ❑ PUMP STATION <br /> OUTBUILDING \ \ <br /> 1 <br /> SEPTIC <br /> EEO <br /> 228 1N.S.1.D. <br /> N <br /> — Dq U;N <br /> SCHULTE ROADi " Hilil4i I I i i I H� I <br /> Hill 11 + 1 <br /> - - - - - <br /> DEPARTMENT USE ONLY <br /> — <br /> Application Accepted By Date J Area Employee ID# ������' <br /> Grout Inspection By ter• Date T ❑ SPECIALWell Permit <br /> Pump Inspection B Date :1 WAIVER Received <br /> Soil Boring Inspection By Irk Date Constructed We I Depth ft <br /> COMMENTS h u F� 'i�'1 A-<- ZI+�` �u�w� <br /> vv <br /> PE SC Received Check Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B ash Remitted Service Request# <br /> f 80 440 50008 3* °`' I I� t azo 0�"3�—�� 3 Ip3 U2 <br /> 3 . "� d Ob.9 c� IK i5 " 1'Z�d�3 p(�3°1322 <br /> EHD 43-06t7 WELL/PUMP PERMIT <br /> 9/28/07 <br />