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WELL/PUMP PERMIT <br /> qox J0AOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 EAST MAIN STREET-$TOCKYON CA 95202 (209)468-3420 <br /> �.� <br /> NON-REFUNDABLE PERMIT <br /> 2 , CALL[2209)953-7697 FOR INSPECTIONSEXPIRES 1 YEAR FROM DATE ISSUED m <br /> JOBADDRESS / I J � - — CITY/zzip pgD 1 <br /> CROSS STREET APN/ / t�q— (.D/—�(J9 PARCEJL SIZE • LAND USEgAPPLaICATION#�,.r/ <br /> OWNER NAME �G6 �Z. �Il-' /// !" Y� � PHONE �+.1�V~ �V F7eb• , <br /> OWNER ADDRESS <br /> CITYISTATEMP <br /> CONTRACTOR <br /> PHONE 7 <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP fNW.Y n/ l <br /> SUBCONTRACTOR _ <br /> PHONE <br /> I <br /> CITYISTATE/zIP <br /> SUBCONTRACTOR ADDRESS ' <br /> LICENSE ,.�-57 O C$1 D D-09 U other <br /> _ NUMBER ( ExPIRwTION DATE <br /> GEOGRAPHICAL INFORMATION! Coordinates X <br /> Y Township` Range__-Section <br /> INTENDED USE DomesUcJPrivate U Irrigation/Agricultural 0 Industrial U Water Ouality Monitoring n Sall Sampling/Characterization <br /> ❑Public Water Syatemya em eme ---UDMW(varve or re um r �I <br /> tf OlHerent fmm Owner. er <br /> TYPEOr oR )<'lewwell U Replacement Well ❑Well Alteration/Modification aer o0o Wither aor tarlDgs <br /> #of wells U Soil Boring(S)s U Geotechnlcal <br /> I U Monitoring Well(s) 9O ' <br /> [3 put-of-service Well DOut-Of-Service Well Renewal ❑Cross-Connection Repair <br /> )tCNew Pump U Pump Replacement ❑Pump Repai —r <br /> WELL CONSTRUCTION <br /> �� �I <br /> Drilling Method>6TMud Rotary D Air Rotary n Auger D Cable Tool U Push Point ❑ Other <br /> '� 1 <br /> Proposed Well Depth0;ft Excavatlon_�.,in diameter ❑Open Bottom ravel Pack/Gravel Size in diameter \' <br /> ❑Conductor Casing in diameter / Conductor Casing Depth ft <br /> t` <br /> Well Casing Diameter ,in Thickness/Gauge/ASTM Schad ❑Steel Plastic ❑Stainless Steel D Other <br /> 1 <br /> Grout Seal Depth .(__it - U Neat Cement(94 111 bag/5-TO gal water) X§and Cement seck.mix/7 gal water <br /> L,Bentonite(20%solids), D Other m <br /> ,,ll__ ❑Retardant/Accelerator(name) <br /> Grout Placement Method7.�•umpetl O Free Fall n Other , <br /> EDes AL Inatellod By rillet O Pump Contractor FI Other <br /> O Concrete Pedestal Dimensions:Width_�, it Length fl Thick in ChristyBox ❑Stove Pipe <br /> 1pump <br /> SUbmereiWen Turbine D Other HP Pump Set it Standing Water Level it <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE wltn 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 C_pLIFORNIA CONTRACTORS STATE LICENSE BOARD.AND THAT 1�IN COMPLIANCE.WITH ALL <br /> i 'WORKERS COMPENSATION LAWS:- <br /> INIMUM 24 FOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> ATE <br /> TITLE <br /> SIGNED _ <br /> l � <br /> / <br /> O - <br /> , <br /> G <br /> S ' <br /> I 5 <br /> S V <br /> >q _ <br /> i Z - <br /> !R N U <br /> n <br /> Pq <br /> �• .�-� .,:.�D-E-P-A`R-TM-EN-T tT3'E_O`ML._ ._ ._•__ .-.. .- Win:—"''� <br /> Empoyee ID# 577y� /�1t <br /> .._ Date_—`- d� Area_ l _. I <br /> Application Accepted By <br /> Date ❑ SPECIAL well Permit <br /> GrouI Inspectlo / WAIVER Received <br /> I Pump Inspection — —; Date ' <br /> ConstructedNlptl Depth ft <br /> Soil Boring Inspection By ' <br /> i COMMENTS ' - I +->`7�" U <br /> Permit/ Well ION <br /> PE SC Received he Amount Date Invoice# <br /> Codes Info 8 ash Remitted <br /> $erVlceR uestq <br /> 3CO& cso (,b X04.1 _ N19109 OAC 8 POpa <br /> 4 y3gp osu s().I lv OD�BSoz. <br /> WELL/PUMP PERMR f', <br /> D - <br /> 9r1&07 u _- <br />