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WELL 1 PUMP PERMIT (' (� " <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH 6EV;RTAIENT 304 E WEBER AYE 3"°FL-STOC ON 9 0 209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS CITYIZIP _ _ m <br /> nn �/ j Gj �r d <br /> CROSS STREET /J I�C�t (� jAPN 01 { 0 '-'I�SKIZCEL SIZE LAND USE APPLICATION <br /> /#��y <br /> OWNERNAME 4�9" C. ��I�4Z1�. )PHONE/ 9CJ /7pdl`0?97 Yn <br /> ( NNERADDRESS 5 ffi 15 CITY/STATFIZIP <br /> CONTRACTOR PHONE <br /> CONTRACTOR ADDRESS CITYISTATEIZIP <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE ❑C-57 ❑C-61 ❑D-09 ❑Other NUMBER EXPiRATiON DATE <br /> GEOGRAPHICAL INFORMATION. Coordinates X Y Township Rang¢ Section <br /> NTENDER USE ❑Domestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization <br /> Cl Public Water System <br /> if different fromOwner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification ❑Other <br /> ❑Monitoring Well(s) #ofwells 0 Soil Boring(s) 4 of borings ❑Geotechnical #ofborings <br /> ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑Crass-Connection Repair <br /> ❑New Plump Pum R lacement ❑Pump Repair <br /> WELL CONSTRUCTION <br /> Drilling Method ❑Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool C7 Push Point ❑Other <br /> I <br /> Proposed Well Depth It 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 ❑Steel ❑Plastic ❑Stainless Steel ❑Other ry� <br /> Grout Seal .Depth ft ❑Neat Cement(94 lb bag/5-10 gal water) ❑Sand Cement sack mix 17 gal water t`' <br /> ❑bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted <br /> Grout Placement Method ❑Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑ Other <br /> ❑Concrete.Pedestal Dimensions:Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe <br /> PUMP Submersible ❑Turbine. ❑Other HP---3 Pump Set 2 IWr- ft Standing Water Level 57— 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 <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL °t7 <br /> WORKERS COMPENSATION LAWS. <br /> MINI U_ 4 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> SIGNED TITLE DATE <br /> y <br /> 4 All, <br /> i <br /> i <br /> 1 <br /> you <br /> DEPARTMENT USE ONLY ([ <br /> Application Accepted By Date !L L0 Area Employee ID# 57,3(� d <br /> Grout Inspecti y Date 13 SPECIAL Well Permit <br /> Pump Inspect n By -G Date '���� ❑ WAIVER Received <br /> Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received 1 C AmountPermit/ Invoice# Well ID# <br /> Codes Info B Cash 2 Remittedpale/ Service Request# <br /> 43 -C-1 tis 0 Sn pi) <br /> ERD43-02-006 WELL PUMP PERMIT <br /> 1/27A200i <br />