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WELL/PUMP PERMIT <br /> _ SAN JOAQUIN COUNTY Ewtito MENTAL HEALTH DEPARTMENT 304 F.WP.EER AvE 31°'FL-ST43CKTON CA 9520.2 •(209)/68-3420 <br /> NON-REFUNDABLE PERMIT CA 1j,(2091953-7697 FOR NSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED m <br /> 2TfX <br /> JOBADDRESS <br /> S- (-1TYlZ1P �� "'� - - O <br /> S �i <br /> CROSS TaEET G/NAJ� �� � APN �5.2.� uRU. If�ARCEL SI� z>; f'2�-LAND DISE APPL7CA7'ION# <br /> SS z � <br /> OWNER NAME PHONE y/11-i <br /> OWNER ADD aEss • CrrVtSTATRMP Q f <br /> CONTRACi'OR Lr. - PHONE <br /> CONTRACTOR ADDRESS •y'• Crl'Y/STATPIZI! <br /> PHONE <br /> SUBCONTRACTOR <br /> SUR'ONTRACPOa ADDRESS l CrfY1STATFIZIP <br /> LICENSR DC-57 0C-61 00-09 jr0they / Z/ NUMBER ExPiRATION DATE <br /> GEOGRAPHICALIKPORMATION; Coardtflates X Y Townsbip_ Range SeclieR <br /> INr9NDED I SE CDomesticlPrivate 0 Imption/Agricultuml E3 Industrial 17 Water Quality Monitoring O Soil Sampiing/Chatacterization <br /> ❑Public Water System ' <br /> If diml from O.�+x+ w Yw-• 1fC <br /> TYPE OF WORK ❑New Well 0 Replacement Welt D Well AltemtioNModification ❑Test Hole D Other ear aarl r <br /> C3 monitoring Well{s) #of wells ❑Soii$oring(s) rof.l-.p D Geotochnical <br /> D Well Destruction a Out•Of•Service Well D Out-Of-Scrvice Well Renewal <br /> E7 New P;kmp ;*Pump RSelacement L3 Not a it Cl Cross-Conrtection Repair <br /> WELL CONSTRUCTION <br /> Drilling Method D Mud Rotary D Air Rotary D Auger D Cahlt Tool D Push Point 0 Other i <br /> Proposed Well Depth n Excavation in diameter CI Open Bottom 0 Gravel Pack/Gravel Size in diameter <br /> D Conductor Casing in diameter / Conductor Casing Depth ft va <br /> Welt C"ug Diameter i in Thickness/GaugeASTM Schell El Steel 13 Plastic 13 Stainless Sral (3 Other �O <br /> Grout Seat Depth ft ❑Neat Cement(fl41h hag/5.10 gal wafer) Cl Sand Cement sack mix 17 gal water y <br /> 0 Bentonite(20'//solids) D Manufacturer Spec%solids_% Name O Specs on File ❑Specs Submitted• 11 <br /> Grout Placement Method D Pumped ❑Free Fall ❑Other f3 Retardant/Accelerator{name) <br /> PEDESTAL I nstallsoO Driller E3 Pump Contractor E3 Other <br /> D Conermem <br /> ete Pedestal Dilons: Widthft Ltngth_ft 'chick in .D CilrlstY'Box ❑Stove�Wpt <br /> PUMP ubmcrsibte 0 Turbine ZI Other HP Pump Set ft Smnding Water Lcvcl 11.E ft <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. i ALSO CERTIFY THAT MY REQUIRED LICENSE IS t <br /> CURRENT AN ITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT i AM IN COMPLIANCE WITH ALL <br /> f) WORKS MPEN <br /> l ti1MU VANCE NOTICE UIRED F R INSPECi'ICIP <br /> TrrLE DATtd <br /> St u <br /> -1` <br /> u <br /> 1= � <br /> A <br /> DEPARTMENT USE ONLY <br /> ApplicationAcccpted By •u• Dain, Area +;Ll Employee IDN <br /> Grout Inspection By Date D SPECIAL Well PeTMit <br /> para r'' i3 WAIVER Received <br /> Pump Inspection -- <br /> - <br /> Destruction Inspection By <br /> Date Constructed Well Depth R <br /> COMMENTS <br /> PE SC AntAt Permit/ .nvocet Well tD# <br /> Received ChecDale <br /> Codes In B ash .Remitted Service R D1esi# <br /> WELL PUMP PEA WT <br /> EMD�34b00 <br /> N&bt <br />