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WELL/PUMP PERMIT <br /> SAN JOADUIN COuNIY ENVIRONMENTAL HEALTH DEPT 1868 East HazeltOn Avenue-STOCRTON CA95205.6232-(209)468.3420 <br /> NON=REFUNDABLE PERMITT�-CALL 209` 9153.7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JoSADDREss 7.g 0 r7 d �� .JOLV IS 1>0 CmZP 46d;1 az q2 <br /> CROSS STREET (� APN 06'--0'\—O 1Z PARCELSRE�—LAND USE APPUCATmN# <br /> OWNER NAME *2300 <br /> I} o e l ,1 C �] / PHONE l r7i 9`18-n47 bbb <br /> OWNER ADDRESS L )0OL/ N DQV\J le- CITYISTATE F/_OG/ / rc. <br /> �cq<� <br /> :i <br /> CONTRACTOR inO PHONE 2IQA <br /> CONTRACTORADDREGS VIA CITY/STATFJLP M^ Z <br /> )"rO <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS ChY/SQQ21 <br /> TATEP , <br /> UCENSE C-57 D C-61 ❑ Omar NUMBER 6 EXPIRATIONDATE J7 X36 <br /> GEOGIUIPXICAL INFGRMAmGN: C IhaSeeX V Township_ Range_ Section— <br /> In <br /> USE ❑DOmeStiC/Pnv to IRlgation/Agriculturel ❑ Industrial ❑Water Quality Monitoring ❑Soil Sampling/Charactedzation <br /> Q.Panc Warafer yseem <br /> % w -tm ser yam eme n00 N.m ana um <br /> TYPEOFWO Na Wap ❑Replacement Well ❑Well Alteration/Modification ❑Other <br /> onitoring Well(s) #ofwells ❑Soil BOdng(s) #meaheas 0Geowchnical #mwdnw <br /> ❑Out-Cf-Service Well O OuWX-Service Well Renewal O Cross-Connection Reparr <br /> D New Pump T1Pump Replacement ❑Pomp Repair ❑Raisa Well Casing <br /> WELL ON <br /> CON O . <br /> Drilling Methotl ud RDry ❑ ❑Auger ❑Cable Tod D Push Point ❑ Other <br /> Proposed Wall'Depth Obrllotary E..vation Z7 In diameter ❑Open Bottom Gravel PacldGravel Size In dlameter <br /> OCo a in clamaler / Conductor Casing Depth h <br /> Well Casing Diam r in ickneas/GauBa/ASTM Schad O• 50 Steel ❑Plastic O Stainless Steel ❑Other <br /> Grout Seal De ft ❑Neat Cement(94/b bag3-T0 gal water) ❑Sand Cement �..3 sack miw7 gal water <br /> ❑ enW D%solids) ❑Other <br /> lGroutplacernent Math umpetl ❑Free Fell ❑Other ❑Retardant I Accelerator(name) <br /> PEDESTAL Installed By ❑Driller VPump Contractor ❑ Other <br /> ❑Concrete Pedestal Dimensions:Width_ft Length ft Thick In ❑Christy Boz ❑Stove Pipe <br /> -------------- <br /> PUMP ❑Submersible❑Turbine ❑011ier HP Pump Set it Standing Water Level ft <br /> 1 HEREBY CERTIFY THAT I RAVE 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 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MINIMUM 24 HOUR ADVANCE NOTICE REOUI,RIED FOR INSPECTIONS <br /> SIGNED V TITLE b r 1 `1Pt DAA -13- l3 <br /> y- <br /> 04 <br /> AU <br /> hie <br /> ! <br /> F <br /> r <br /> DEPARTMENT USE ONLY <br /> APPeCEUOn A=P. <br /> Grout Inspection B / Date S SPECIAL Well Per lit <br /> Pump Inspecpon By Data WAIVER Received <br /> Sou Boring Inaooaec�yyon BY Data Constructed Well Depth N <br /> COMMENTS <br /> PE Sc Received hes Amount Date Psora Invoice# Well ID# <br /> Codas Info BY Remitted Service Ra uest# <br /> 61 . 190 4,1— gioo -7149 <br /> SHE, 09 WELL PUMP PQN1n <br /> ems OB <br />