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1 <br /> WELL / PUMP PERMIT@L- <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT �� 304 EWEBER- REAR <br /> �0 (209)468-3420 <br /> NON-REFUNDABLE P/E�RMIT. j CALF(209)953-7697 FOR INSPECTIONS EE FROM ATE ISSUED' <br /> JOB ADDRESS 6- , rT CITYIZIP �� _ rn <br /> CROSS STREET ZI f e— l%6L APN ''..CEL SIZE LAND USE APPLICATION# V <br /> OWNER NAME �LL V I l_d/✓UI ILa_S�f r _ PHONE O L—Z hof <br /> OWNER ADDRESS /�r'TW CITYISTATE/ZIP f +r <br /> f�J�v'�/ T f f <br /> CONTRACTOR I N PHONE <br /> CONTRACTOR ADDRESS E CITYISTATE/ZIP 1114 <br /> i <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS <br /> CITY/STATE/ZIP` <br /> tom^ <br /> LICENSE, C-57 ❑C-61 ❑D-04 ❑Other NUMBE 1f-- EXPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE Domestic/Private 0 Irrigation/Agricultural Cl Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization <br /> ❑Public Water System <br /> [f different from wner: Waier Tystern Name Contact Name orNione Number <br /> TYPE OF WORK XNew Well ❑Replacement Well ❑Well Alteration/Modification El Test Hole ❑Other <br /> 11 Monitoring Monitoring Well(s) #of wells Soil Boring #of borings ❑ <br /> Boring(S) Geotechnical Of of borings <br /> ❑Well Destruction ❑Out-Of-Service Well ❑put-Of-Service Well Renewal <br /> ❑New Pump 1 ❑Pump Replacement ❑Pump Repair ❑Cross-Connection Repair <br /> WELL CONSTRUCTION <br /> Drilling Method ❑Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Other <br /> Proposed Well Depth ft Excavation in diameter ❑Open Bottom Gravel Pack/Gravel Size in diameter <br /> ❑Conductor asing in diameter ! Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched, a ❑Steel �41astic ❑Stainless Steel El Other <br /> Grout Seal Depth ft ❑Neat Cement(94 Ih hagl5-10 gal water) ❑Sand Cement sack mix 17 gal water <br /> Bentonite(20%solids) ❑Manufacturer Spec%solids % Name �j*"dlk 13 Specs on File ❑Specs Submitted <br /> Grout Placement Method Pumped Cl Free Fall ❑Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑Driller 1-,nPump Contractor ❑Other <br /> ❑Concrete Pedestal Dimensions: Width ft Length ft Thick in ❑Christy Box ❑Stove,Pipe <br /> I <br /> PUMP ❑Submersible ❑Turbine ❑Other HP Pump Set ft Standing Water Level ft <br /> i <br /> 1 HEREBY CERTIFY THAT 1 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 1S <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> i1 MINIMFP�.24 HOUR ADVANCE NOTIC y REgU /�%j�ED FOR INSPECTIONS <br /> SIGNED <br /> f _ TITLE 1 7� DATE /j�q% �}4 <br /> —r <br /> 1 <br /> i <br /> t <br /> i <br /> I <br /> 4 <br /> SM,1 q <br /> TA <br /> cepD�� T-1)S rO N G Y <br /> Application Acted.By.-,__._ ._ _,_ _ Date - _ ._ - _. . Area - Employee ID <br /> Grout Inspection B Date ��/ ❑ PECIAL Well Permit <br /> p Y - <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Destruction Inspectgin.By Date Constructed Well Depth ft I <br /> PE SC Received Check#1 Amount Permit/ I <br /> Codes Info B as Remitted Date Service Request# Invoicr ell 1 <br /> -+ 1438 I ' 0 -3 S 1 vP6o z o 7 qt <br /> EHP 43-02-006 - WELL PUMP PERMIT <br /> W104 <br />