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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMEM 301E WEBER AVE 3"FL-STOcar0N CA 95202 -(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTION'S EXPIRES I YEAR PROM DATE ISSUED <br /> JOB ADDRE96 Cm'/ZIP y <br /> C.vrry RcD cc)) �( AR ° <br /> CROSSSTREET �O 'f-'a 1� -� APN U(II 1 "1 PARCELSIZE�I—LAND USE APPLICA�TjION# '/ / <br /> OWNERNAME Vat r LDTTA� j PHONE <br /> OWNER ADDRESS %CA,Mf- ^ CRV/STATE21P <br /> CONfMCTORS//ILA# �y�{Lfl[!Z M�J�I" tL t7[A.))In PHONE <br /> �4ZJ <br /> CONTRACEORADDRESS YII �Y� Irl / CITU/STATE/ZIP <br /> SUBCONTRACTOR PHONE 4 <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP Y� //p./, <br /> LICENSE 0C-57 0C-61 0D-09 OIFa NUMBER ExPIRAT1oNDATy A/y/e <br /> GEOGMPHICALINFORMATION: Coordinates X Y Township_ Range_ Section <br /> INTENDED USE mestie/Privme 0 Iniption/Agricultural 01^dustrial ❑Water Quality Monitoring O Soil SampliaP/Chameterindon <br /> ❑Public Wats System <br /> UEHfema Tmm .Nr y.Rm .m. Con.N.m um <br /> TYPE OF WORK 0 New Well ❑Replacement Well 0 Well After tian/Modification ❑Other <br /> O Monitoring Well(s) 0ofwells ❑Soil Bmi^g(s) aOrap11K' 0Geotechniml aofbodnp <br /> 00ut-O&Servke Well 0Our-0O&Service Well Renewal ❑Cross-Connection Repair <br /> 0 New PumE 0 Pump Reelournew, top Repair <br /> WELLCONSTRUCIION <br /> Drilling Method ❑Mud Rotary 0 Air Rotary 0 Auger ❑Cable Tool 0 Push Point 0 Other <br /> Proposed Well Depthft Excavation i^diameler 0 Open Bottom ❑Gmvel Pack t Grovel Sim in diameter (� <br /> ❑Conductor Casing in diameter / Condugor Casing Depth R <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Schur 0 Steel 0 Plastic 0 Stainless Steel E3 Other <br /> Groot Seal Depth It ❑Neat Cement(94/b bog/540gat weer) ❑Sand Cement sack ark 17 gel water <br /> ❑Bentonite(206/b solids) ❑Manufacturer Spec%solids % Name 0 Specs on File 0 Specs Submined <br /> GTDDIPlacemenl Method ❑Pumped OFra Fell ❑Other 13Retardam/AceelemmT(name) <br /> PE�cTrwL Installed By ❑Driller m.pump Contractor Other <br /> OCcuscreraPedestal Dimenalom:WHUh R �.. <br /> Length ftThick in ❑Christ'Box 051ove Pipe <br /> PUMP mereible O Turbine ❑Other HP Pump Set ft Standing Water Level H <br /> 1 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 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION L.47S. <br /> /7WlN�° <br /> M 11�UUR ADVANCE NOTICE [RED FOR INSPECTIONS /� <br /> SIGNED TITLE DATE / <br /> Li <br /> E <br /> G un <br /> T OPA <br /> L <br /> 0 <br /> LA or� [t I---- 1 11 1 1 —/ I <br /> at <br /> r--L- - : I I � I I I I -HEM- <br /> E 'MENT USE O LY <br /> +Application Accepted By / Date Area _ EmployeeID#� <br /> Grout InspationB Date 13 SPECIAL Well Permit <br /> PUMPlnSpon Data��//�Ld� ❑ WAIVERRecelved <br /> Canslrualed Well Depth ft <br /> COMMENTS <br /> PE Sc Rae ad Cbak#1 Am um Data Permitt Invoke# Well IDN <br /> Coda Info B ae Remitted SerAce Beal# <br /> Z— <br />