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LW WELL 1 PUMP PERMIT . 1J01 <br /> SAN.IOAQM COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 301E WEBER Avli 3'O FL-SrocttTON CA"M-(209)468.3420 <br /> NON-REFUND <br /> JABL <br /> E PERMIT Jr CALL(209) <br /> 953-7697 FOR INSPECTIONS EXPI�+R�pC�S I YEAR FROM DATE ISSUED y <br /> JODADDREM 1,3711 Cf 9' I�1 - — CRY/ZIP " ? <br /> v <br /> CROSSMM r7 C��..tl� _APN /ZO��/�+J.-�_PwACEE.317E WND USX APPLICATION# <br /> DwNLRNAKR 14���Itl-I � /i I-r/l1� _ PHONB <br /> DINNER ADURESS Crry SrATPJZIP '1"iU/�r� yy� <br /> CONTRACTOR �`t%I1�r1J�'rL`F%1 J']r 1�, �✓Lt,^. _ _. PHONE l�aej 1 Ur �1:.1'0 <br /> CONTRACrORADDRE8E {i L-C II' �Tly �r. _ CrMMATLMP � <br /> SUBCGNrRACrOR PHONE <br /> SuacoNTRACPOR ADDRESS CITY/SFATE/LrP / <br /> LIcssm C•57 O C-61 0 D-09 O Other NUMBER E%PIRATTON DATE 9- Q+a <br /> GP.OGRAPHICAL INFORMAl7ONt Coordloatea X Y Township— Range SecNon— <br /> jN3XIp$D 12SE fl Domestieff rivste 0 lrrigation/Agticultural ❑Industrial 17 Water Quality Monitoring Soil SamplingrCharacteriaation <br /> 0 Public Watcr Syysatem <br /> lydifferoat Sam Ovnrr: .W r� me W Pffma <br /> I=OF WORK O New Well G Replacement Well O Well Ahcration/ModiScation a Other <br /> oar <br /> O Monitoring Wdf(s) #ofwells O Sail Boring(s) surbarings OGcotechnicai <br /> 0 Out-0F-Service Well 0 Ont-Of-Service Well Renewal 0 Crosa-Connection Repair <br /> I <br /> 0 New Pump O Pump Replacemen O NM Repair <br /> i <br /> Driving Method O Mud Rotary 17 Air Rotary XAuger O Cable Tool O Push Point 0 Other <br /> Proposed Wdf Depth.lJt=.J-Q ft Excavationjj 11_7 in diameter 0 Open Bottom O Gravel Pack/Gravel Sias, in diameter <br /> O Conductor Casing ' in diameter I Conductor Casing Depth R <br /> Wall Casing Diameter_in Thickne.4bogdASTM Sched 0 Steel 0�,t Piastie 17 Stainless Steel (Other h <br /> Groat Seal Depth ft O NeaL Cement(941b bag/S-10gdl wmIu er} Sand Cement I sack mirt 7 gal water <br /> O Bentonite(20%solids) 0 Manulactum Spee%solids % Narne 0 Specs on de O Specs Submitted <br /> Grout Placement Method O Pumped 0 Free Fall 0 Other O Retardant/Accelerator(name) <br /> ELINVAL Installed By . O Driller 0 Pump Contractor 0 Other y) <br /> 0 Concrete Pedestat Dimembm:Width fl length ft Thick in 0 Christy Box 0 Stove n <br /> PUMP 0 Submersible O Turbine p Other HP Pump Set fl Standing Water Lcvd <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. 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 COMPENSATION LAWS. <br /> Z9INIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIOPS <br /> SIGNED r1 Tnu } DATE �+ <br /> r <br /> IE- <br /> r <br /> r... I <br /> . +tis• <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date J? L'5' Area Employee IDN <br /> Grout Inspection ByDate r�E-+7or1S C3 SPECIAL Well Permit ! <br /> Pump Inspection By Date ❑ WAIVER Received <br /> I <br /> Constructed Well Depth D <br /> COMMENTS <br /> PE SC Received Check#!— Amount Date permitl Invoke Well]DO <br /> Codes Info By Ate-Itted Servlu Requag0 <br /> L{37). <br /> �rl-07� wELL]'t1I4P PSaMIT <br /> rmnoas <br />