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10-A rl <br /> (WELL / PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH L.------tMENT 304 E WEBER., 3"°FL-STOCIcrON CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS X-113 /IAir''1 STi CITY/ZIPCk-ror2 gS2IS <br /> CROSS STREET �WAI1�r L . APN ��% -�170r"l9Eo/ PARCEL SIZE f �� LAND USE APPLICATION# <br /> OWNER NAME •��� �l�yfMer��� �� rPHONE y^� <br /> OWNER ADDRESS Gn/1Cly �Ar1 AVECITY/STATE/Z1P JTOGM7ri» J a Ca, Q )S";G2a <br /> CONTRACTOR IS)e in+F/tier PHONE Ca�93�y8p/3S3 <br /> CONTRACTOR ADDRESS �f3aZ E. 2f'l erY7e ffree-r CITY/STATEIZIP57�.Gr3-, <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE C-57 ❑C-61 ❑D-09 0 Other NUMBER :W7952 EXPIRATION DATE /,:!z <br /> d <br /> GEOGRAPHICAL INFORMATION: Coordinates X 7. 'Co <br /> Y /oZ J, oZ t./ Township Range Section <br /> INTENDED USE ❑Domestic/Private ❑Irrigation/Agricultural 0 Industrial ❑Water Quality Monitoring Soil Sampling/Characterization " <br /> ❑Public Water System <br /> if different from Owner: Water Systerm Name Conuict Nome or Phone Number <br /> TYPE OF WORK 0 New Well ❑Replacement Well ❑Well Alteration/Modification ❑Other <br /> ❑Monitoring Wells) #of wells ❑Soil Boring(s) #of borings "n Geotechnical #ofborings <br /> ❑put-Of-Service Well 0 Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> ❑New Pump ❑Pump Replacement ❑Purnp_ReLmir <br /> WELL CONSTRUCTION <br /> Drilling Method ❑Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Other <br /> Proposed Well Depth jn ft Excavation in diameter ❑Open Bottom 13 Gravel Pack/Gravel Size in diameter <br /> ❑Conductor, asmg in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter _n?, in Thickness/Gauge/ASTM Sched ❑Steel Cl Plastic ❑Stainless Steel ❑Other (.v <br /> Grout Seal Depth ft ❑Neat Cement(941b bag/5-10 gal water) ❑Sand Cement sack mix/7 gal water <br /> ❑Bentonite(20%solids) Cl Manufacturer Spec%solids % NameSpecs on File 0 Specs Sub fitted <br /> Grout Placement Method ❑Pumped ❑Free Fall ❑Other 13Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑Driller ❑Pump Contractor 0 Other <br /> ❑Concrete Pedestal Dimensions:Width ft Length ft Thick in ❑Christy Box O Stove Pipe <br /> PUMP ©Submersible ❑Turbine ❑Other HP Pump Set ft 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 /> 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 /> MINIMU' 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> SIGNED w . TITLE S/ATT ee-/" DATE <br /> F <br /> o ��� I <br />��..,.,- �....:�-:i.; .-"_'�`�;K`U'E`I':A i2-•P']s1-E-hf-Tl <br /> ispection <br /> ccepted By Date :iArea Employee ID# ` e <br /> B Date 13 SPECIAL Well Permit q <br /> Pump Inspection By - ` -- Date �- ­X3 -WAIVER Received <br /> Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check# Amount Date Permit/ Invoice# WellID# <br /> Codes Info By Cash Remitted Service Request# <br /> 'F3- Z iso 230.,0 O 30 <br /> EHD 43-02-006 WELL PUMP PERMIT <br /> 1127/2005 <br />