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{ - o <br /> WELL!PUMP PERMIT �O <br /> yAN JOAQu1N CODNTv ENVIRONMENTAL HEAI.T11'DEPARTMENT 301 E WERRAAYE J'°PL-Si1OCKTON CA 95201 -(209)463-3420 <br /> NON-REFUNDABLE PERMIT ry CALL 209 953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED <br /> so <br /> JOBADURESS 1.,r 1 r�(,�y�� <br /> 1 ��/} —1•_- II ClrrrLlr <br /> CROSSSTREET C�t+ AP?! j-SIG--.I ka PARCEL SIEE '"3E LAND USE APPLICATION!) Ia <br /> OWNERNAME PRON `r <br /> OWNERADDRr_SS CITYlSTATTJZIP t <br /> CONTRACTOR 7 V S r 00 - <br /> _ PHONC <br /> I� k <br /> CONTRACTOR ADDRESS CITYlSTATFJ2IP <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CrO5/STATE/ZrP M <br /> LICENSE ❑C-57 ❑C-61 ❑D-09 WOthe, NU.NBER EXPIRATION DATA/ <br /> 1 GEOGRAP111CALINFORMATIOV: Coordinates X Y Township_ Range Section_ <br /> INTENDED UNIE D0MC5tiCJPrfv2te ❑2rrigati4Dn1Ag6cttllura1 ❑Industrial El Water Qualify Mon)torinS 0 Soil Samphng/Characmriation <br /> E3 Public Watcr Syys8tem <br /> If rrtS-nt VOvva seer yvrm ams .om.rt N.m.r one <br /> TYPE OP WORK O New Well D Replacement Well ❑Well AlieratiunlModiflcadon 13 Teal Hole CI Otho <br /> ❑Monitoring Well(s)_#arwclls D Soil Borin a 1011-11, a afborinq <br /> g() ❑Goateehnicel <br /> CI Well Destruction ❑Ou1-0f-Service Well O Out-Of-ServicC Well Renewal <br /> ❑New PI!MP VPUT12 R lmcmcnt b Pump Repair ❑Cross-Conntction Rcp&ir t <br /> WELT.CONSTRUCTION <br /> Dril1[ng Method ❑Mod Rotary ❑Air Rotary D Auger ❑Cable Tool O Push Point ❑Other ' <br /> Proposed Well Depth ft F:xcavatioh. in diameter Q Open Bottom ❑Gravel Pack I Gravel Sizc in diameter <br /> 0 Conductor Cung_in diamecr I CunductorCasingDepth R <br /> Well Caring Diameter_in ThickneadGauge(ASTM.Schell ❑Steef O P;astic ❑Stainless Sleet ❑Other <br /> Grout Seal Depth R 17 Neat Cement()4(h bag IS-lOgul wrrrer) D Sand Cement .ruck mix 17 gat water <br /> l <br /> ❑Bentonite(20'/solids} ❑Manufacturer Spec%solids_% Name_ ❑Specs on Flk p Specs Submitted l <br /> Grout Placement Method I]Pumped 17 Free Fall O Other C7 Retardant/Aceeleralor(name) N <br /> PEDESTAL rnatafled_By Q Driller ❑Pump Com*actor ❑Other ; <br /> l ❑Concrete Pedestal Dimensions Width_ tl Length fl Thick in ❑Christy Box ❑Stove Pipe r t; <br /> I <br /> PUMP Submcnible ❑Turbine C3 Other _ HP Pumpse, R SuttldingWatc,Level- ft m <br /> I 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 REGULATTONS. 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 .O t <br /> i WORKERS COMPENSATION LAWS. <br /> MIN)19UM24HOUADVANCENOTIC IR FOR INSPECTIONS C <br /> r <br /> SIGNED TIT DATE I { <br /> re <br /> I VI <br /> a . <br /> lv � - <br /> I <br /> i <br /> T <br /> E V <br /> I <br /> DEPARTMENT USE ONLY HEALTIi DEPARTMENT <br /> 646 <br /> Cy <br /> Application Accepted By � c.� _. Date fl U Area 2-( ! EMPloyce ID# ti�V 9 <br /> Grout Inapoction By Date ❑ SPECIAL Well P4Tmill , <br /> Pump Inspection By pate ❑ WAIVER Received , <br /> DCytwction In.ptx:tion H Dew Cortalrncted Well Depth T• ; <br /> COMMENTS <br /> 0101, <br /> PEF SC Received AkwukulAmount Date PtrmiU invokes WcII ID,Y <br /> Cadet Info 8 Cash Remitted ServiitR uetfM <br /> 3•�! ala <br /> F.HO�S-07-mOh <br /> WELL PL W P PERMIT <br />