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{ <br /> WELL/PUMP PERMIT SCANNED ° <br /> SAN JOAOHIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304E WEBER AVE 36°PL-STOCKTOrc CA 95202 -(249)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> E JOH AODAess / ��/J C 1 T CITY/ZIP__.CiLa_m e�M1` n <br /> CROSS STREET 14 Y2. F („�t/) <br /> APN "�— n <br /> -�tt PARCEL S[2E LAND USE <br /> �A'P]PLI C+AT+ION# (J � <br /> OWNERNAME <br /> I 1 <br /> ' OWNFR AppAFSS �{ Q CITYISTATE21P 'y^� ' <br /> GONTR � <br /> ACTOA i 4 <br /> IF y./ <br /> r Oen <br /> CONTRACTORADDRESS f V PHONE C/— <br /> CITYISTATEIMP4!� OJ <br /> SUBCONTRACTOR <br /> n PHONE <br /> SUBCONTRACEOR ADUAESS CITYISTATEJZIP <br /> LICENSE -57 ❑C-61 0 D-09 0 Other '7 <br /> NUMBER- 7 EXPIRATION DATE �� <br /> GEOCRAPHICALINPORMATION; Coordinates X Y Townshi <br /> p_ Range Section_ <br /> INTE ED USE �DomesticlPrivate ❑Irrigadt)n/Agricuhural 0Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization <br /> ❑Public Water System <br /> Ifdifferent from Owns: a,er ystem em° aniact ame°r ane um - <br /> TYPE OF WORK�ssNew Wcll ❑Replacement Well 13Wel]AltetationlModificadon ❑Other <br /> ❑Monitoring Wells) #ofwells ❑Soil Boring(s) "b°rings ❑Geotechnical znfhunngs <br /> ❑Out-Of-Service Well <br /> ❑OW-0f-Service Well Renewal BCross-Connection Repair F <br /> ew Pum m❑PuReplacement ❑Pum Repair c <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary ❑Air Rotary Q Auger 11 Cable Tool El Push Point ❑Other <br /> Proposed Well Depth Z-{7 ft Eacavadon -' <br /> in diameter ❑Open Bottom *--.I Pack/Gravel Size in diameter <br /> ❑Condactyr Casing in diameter / Conductor�asing Depth ft <br /> Well Casing Diameter.(� in Thickness/GaugelASTM Sched� 7 ❑Steel 124Siastic ❑Stainless Steel ❑Other <br /> Grout Seat Depth.20 <br /> 0 ft ❑NmtCement(94161wg1J-10gal wnler) E59and Cement <br /> sack mu!7 gal water <br /> C7 Bentonite(20%solids) ❑Manufacturer Spec%solids_% Name ❑Specs on File O Specs Submitted I <br /> Grout Placement Method umped ❑Free Fall ❑Other Q Retardant J Accelerator(name) <br /> 'PEDESTAN Installed By Driller ❑Pump Con[mctDr ❑ Other <br /> Cl Concrete Pedestal Dimensions:Width R Length ft Thick in ❑Christy Box O Stove Pipe <br /> f'^ PUMP Submersible ❑Turbine CI Other HP Set <br /> Pump <br /> r R 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 /> M IMUM 24 HOUR ADVANCE NOTICE <br /> tt'��REQUIR,,EE- �r DFOR INSPECTIONS <br /> + SIGNED /•IV�� TITLE (9W l/S.r'— DATE <br /> l <br /> r� <br /> _ I <br /> I. <br /> } M <br /> 4 <br /> DEPARTMENT US ON Y <br /> Application Accep By I ate I r�d Area Employee tD# <br /> Grout Inspect Dole /�� <br /> 0 SPECIAL Well Permit <br /> Pump Inspec on By - Date! Q WA{YER Received <br /> Constructed Well Depth ft _ <br /> t COMMENTS W v <br /> I . PESC Received eck#/ Amount Permit/ I� <br /> Codes Info B Remitted Date Service Re uest# Invoice# Well IDY <br /> Q �L rr 2 Fs� 2 S 0d Z <br /> 3 C WL-C� X 2-0 5� U 1 do h <br /> EHD41-D2Aa6 -I <br /> { 1,7712005 - - - - . <br /> wEl <br /> 4 <br /> r <br /> k <br />