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Page 1 of 1 <br /> WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 EAST MAIN STREE <br /> NON-REFUNDABLE PERMIT I , CALL 209 953-7697 FOR INSPECTIONS EX <br /> Joe ADDRESS .i 2A �, N W 7 l/ CITY/LP <br /> CROSS STREET APN�_[ lJ r[_. PARCEL SIZE LAA <br /> OWNER NAME / v r <br /> (` �t 1 PH <br /> OWNER ADDRESS ,l-'• '�--'I,�1�/D�tl� I A iA 11 111 �'"{ CITY/STATEZP�i <br /> CONTRACTOR wil``4's A)ellkA IL/L G!bUI C✓ LW-yr;( PH <br /> CONTRACTOR ADDRESS 4.) j To°rlA ave CITY/STATE/71P OA1 IQ <br /> SUBCONTRACTOR ._ PH <br /> SUBCONTRACTOR ADDRESS IlCIIITWSTATE/LP <br /> LICENSE 'Z 57 C-61 D-09 Other NUMBER El <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township <br /> INTENDED USE omesuc/Pnvate Imgalion/Agricultural Industrial Water Quality Monitoring S <br /> Public Water System <br /> If tlfflerent from Owner water System Name -Co Talc T <br /> TYPE OF WORK New Well Replacement Well Well Alteration/ModlHcebon Other <br /> Monitonng Wells) #of wells Soil Borings) a°r lwmps Ge <br /> Out-O(-Se el Out-Of-Service Well Renewal Cross-Connect, <br /> Nev.Pum Re lacernent Pump Repair Raise Weft Cas' <br /> WELL CONSTRUCTION <br /> Drilling MethotlMud Rotary Air Rotary Auger Cable Tool Push Point Other_ <br /> Proposed Well Depth It Excavation in diameter Open Bottom Gravel <br /> Conductor Casing in diameter / Conductor Casing Depth it <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched Steel Plastic Sts <br /> Grout Seal Depth R Neat Cement(94 lb bagl5-10 gal wafer) Sand Cement_ <br /> Bentonite(20%solids) Other <br /> Grout Placement Method Pumped Free Fall Other Retardant/Accelerator(n <br /> PEDESTAL8LIPSy Driller Pump Contractor Other <br /> Cont a Pedestal Dimensions:Width It Length fl Thick it <br /> PUMP Subm ble Turbine Other HP '/0. Pump Set - ) H <br /> I HEREBY C RTIFY T AT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE <br /> JOAQUIN CO NTY DINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIF' <br /> CURRENT AND A VE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THA <br /> WORKERS COMPENSATI N LA S. <br /> I UM HOUR ADVANCE NOTICE RE UIRED FOR INSPE( <br /> SIGNE TITLE <br /> I <br /> file://C:\Documents and Settings\mescotto\Local Settings\Temp\DMCI\D00\1.JPG 6/19/2013 <br />