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Lid`°`{ ;cocicccr�/ , <br /> WELL/PUMP PERMIT <br /> JAN JOAQUIN COUNTY ENVIRONMENTALHEALTR 'MFA'I' 304E WEBER AYE 3"FL-$1 NCA 95202- (209)468-3420' <br /> NON-REFUNDABLE PERMIT ""/.J <br /> /J ��jj// ,1 ALL 209 $3-7697 FOR INSPECTIONS EXPIRES I YE/A�R FROM DATE ISSUED <br /> JOB ADDRESS YC/[-_tlJ_� I�JZ �MiGI- L I.00.L l ' g ^ <br /> CITY/ZIP [ <br /> D <br /> I e <br /> hiss <br /> CROW$TREET 'E wLa..�-("5 K-0. - APN 0532ca <br /> —2 —o4- PARCEL 51LE -O I LAND USE APPUCATIONR / ) pm <br /> OWNER NAME LA V1 �J l/ PHONE 3 U l / J <br /> OWNERAOORMS `/�JJ��JJ —,V, VX/STATFIZIP 9,!;-L2 � <br /> CONTRACTOR /' w 71—r ,IfOT_1 ` PHONE 7-2 <br /> CONTRARORACD'D-RESS /-77 t &", $ CITY/STATEI IP <br /> SUBCONTRACTOR PHONE <br /> Bias SUBCONTRACTORADDRE3S CITY/ST/rA-�TEl H` <br /> LICENSE -5] ❑Cdl OD-09 ❑Other NUMBL Vaj_ EXPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range_ Section <br /> ` INTENDED USE ❑DomaHc/Private ❑IrrigptioNAgncultu al ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Charactuimtion <br /> ❑Public Wamr Syysstaemm <br /> VdiRuoa rem Ownc. war S,.-N onunl NN.w Phone N.uNv <br /> TYPE OF WORK ❑New Well ❑Replacement Well O Well AlteretionWodification ❑TrE Hole m other <br /> Cl Monitoring WcO(s) pof wilClls $oil Borings)_ parbonng, ❑ <br /> Grotrohniul aMtoringr <br /> 1.n ❑Well Desmuctimn ❑OUt-Of-Service Well taf- <br /> Service Wel <br /> cl Renwal <br /> ❑New Pum ❑Pum R Imemut ❑Pump it ❑ m-0Cit <br /> WELL CONSTRUCTION <br /> Drilling Method ❑MW Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Other <br /> Proposed Well Depth R Fxtevation in diameter ❑Glum Bottom ❑Gravel Pack/Gravel Simi.diameter <br /> ❑Conductor Cssing indiameter / Conductur Casing Depth R iR <br /> Well Cuing Diamele_in Thickness/Gauge/ASTM Schad ❑Steel ❑Plastic ❑Stainless Steel ❑Other 1„ <br /> Grout Seal Depth R ❑Neat Cement(94/h be,/5-/0 gal water) ❑Sand Cement .nick out/T gal watt, <br /> ❑Bariumite(2VA solids) ❑Manufacmer Spec%mlids M Name ❑Specson File ❑Specs Submined <br /> r� <br /> Grout Placement Method ❑Pumped Cl Fra Fall ❑Other ❑Retardant/Accelerator(name) m <br /> PEDESTAL Imtallad By ❑Diller ❑Pump Contractor ❑Other <br /> ❑Concrete Pedestal Dimensions: Width_ R Length It Thickm ❑Christi Ba. ❑ ve StoPipe 4 <br /> Pump ❑Submersible ❑Turbine ❑Orher HP Pump Sat ft Standing Water level It <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. 1 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 COMPEN TION LAWS. r <br /> r� MI UM M HOUR ADVANCE NOTICE RFSQPRED FOR INSPECTIONS /?� Z. <br /> Sic nEO TITLE DAre <br /> i <br /> Gal - <br /> t <br /> M <br /> T D <br /> ar <br /> y ., DEPARTMENT USE ONLY t{ <br /> IIS Application Accepted By '�`` Data, 5 0S Area Z(� Employee IDM 531 b y <br /> Grout Inspection Das ❑ SPECIAL Well Permit <br /> Pump Impectio By Das 05 ❑ WAIVER Received <br /> Destruction Inspection Date Constructed Well Depth /y / B <br /> Y• <br /> COMMS <br /> PE SC ReceivedChed Amount Dae Permlo Invoice# Well IDM <br /> ` Codes Info B Remitted $ervian Rue,taut# <br /> .j3.7 OSO SD-C() 1 r `j IZD04 <br /> EHD4T -M{ wELLPUMPPERMIT <br /> Nom <br />