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WELLIPUMP PER 'IM <br /> ✓� -7— �= � <br /> SAN JOAouai COUNTY ENVIRONMENTAL HEALTHDEPARTMENT T MOM <br /> -(209)468-3420 <br /> FFF NON-REFUNDABLE PERMIT 11 �rrtCA1LL`2109 953-7697 FOR INS M DATE ISSUED <br /> J.AMIESS OD �nn�gi6si i�—pI C.r _ CITWLP L 0,)0C— J 9152-35 ...� <br /> SII CROSS STREET �lW Aaj:2�pYAPN - O' PARCEL SIZE <br /> BLAND USE APPLICATION# <br /> OWNER NAME eft P006 <br /> PNONE <br /> OWNERADDRESs 28102 01>/ 6:�-779 CITYISTATMIP Lem Om ce '?52,3j/ <br /> CONTRACTOR <br /> � � C PHONE_?DC7'.U,?-37oi <br /> I CONTRACTORADOREss 02 V (- CITYISTATEMP D S240 <br /> F <br /> SUBCONTRACTOR PHONE ' <br /> SUBCONTRACTOR ADDRESS - CITYISTATEMP �C�F^� <br /> I LICENSE C•57 ❑C-61 0 D-09 0 Other NUMBER—Wqq 025 EXPIRATION DATE 0 v <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> Township�_ Range Section <br /> J INTENDED USE ❑Domesbc/Private ❑IrrigabonlAgricultural ❑industrial 0 Water Quality Monitoring rail Sampling/Characterization - <br /> ❑Public Water System <br /> If dWererd from Owner. ame Goame ar*MNVMW <br /> R <br /> TYPE OF WORK ❑New Well ❑Replacement Well ❑Well AlleratioNModification ❑Other <br /> ❑Monitoring Well(s) #pfwells O SoilBorin s 4af6 rings A'et""" <br /> 9 ( ) g( ) Geotechnical_-� <br /> p Out-OfServioe Well ❑Out-Of-Service,Welt Renewal, ❑Cross-Conner ion Repair <br /> O New Pump ❑Pump Replacement 0 Pump Repair 0 Raise Well Casing <br /> FWELL CONSTRUCTION <br /> . Drilling Method 0 Mud Rotary D Air Rotary XAuger ❑Cable Tool C Push point ❑ Other <br /> Proposed Well Depth rJ-2-_D It Excavation I In diameter O Open Bottom ❑Gravel Pac*JGravel Size in diameter <br /> ❑Conductor Casing in diameter I Conductor Casing Depth it <br /> Well Casing Diameter_irl ThidmesslGsugeIASTM Sched ❑Steel 0 Plastic ❑Stainless Steel ❑Other <br /> Grout Seal Depth It ❑Neat Cement(941b ba9/r10 gal water) ❑Sand Cement sack mbr7 gal water <br /> F ❑Bentonite(20%solids) 0 Other O C S <br /> Grout Placement Method 0 Pumped ❑Free Fall ❑Other ❑Retardant I Accelerator(name) <br /> tlPEDESTAL Installed By ❑Driller C Pump Contractor ❑ Other <br /> 0 Concrete Pedestal Dimensions:Width ft Length R Thick in 0 Christy Box ❑Stove Pipe- <br /> PUMP ❑Submersible❑Turbine U Other_ HP Pump Set It 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 /> 14 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 /> IMUM 24 HOUR VANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED NfAI�C/ <br /> TITLE / Z?IAJII C 6-A DATE-4- <br /> m <br /> KIP <br /> N . �.. <br /> !# <br /> a ..r. Y L <br /> F <br /> PA TMENT U E NLY <br /> FApplication Accepted Date a Area Employee IDT 5}L31JJ`r Aj <br /> Grout Inspection By Date © SPECIAL Well Permit T"� <br /> Pump lnsp y Date ❑ WAIVER Received <br /> SW Baring Insp clip g Date �h Constructed Well Depth It <br /> COMMENTS zizf <br /> PE SC Received (theck6­3 Amount Date Permit/ Invoice# well 109 <br /> Codes Info B Remitted Service Request# <br /> 3 <br /> EFID WELL!PUMP PERMIT <br />