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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH Drpmrrmy wr 3114 E WEBER AYE 3`FL-STocKToN CA 95202 -(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED <br /> ^,��]7 1 <br /> JOBADDRESS —l�--/-_ CrTYIZrP �9T.+c.�.�, ,-,I y <br /> /1 II tv <br /> e <br /> CROSS S`rREET APN{ Z `06PARCEL SIZE /// LAND USE APPLICATION 0 _ <br /> OWNERNAME [A/ l /b � LG r_ !_ PL7 ,P�H�ONEE—Vj—�•j,2!> <br /> OWNER ADDRESS CrrYlSTAT}JZEP <br /> COVrRACfOR PHONE <br /> CONTRALTOR ADDRESS CrrvlSTATFJZH` _, <br /> SURCONTRAc,rOR _ PUONE <br /> SUBCONTRACTOR ADDRESS CrIFYISIArEIZIP <br /> LICENSE ❑C-57 ❑C-61 ❑D-09 ❑Other NUMBER ExPIRATION DATE <br /> GEOGRAPHICALINFORMATION! Coordinates X Y Township Range Section_ <br /> IxrerrDED Use ❑DomestidPrwate ❑IrrigationlAgricultural ❑Industrial ❑Water Quality Monitoring Ll Soil Sampling/Characterimiian C <br /> ❑Public Water System _ <br /> Ifdilroent from LLmer W.W ystem S.mc CmtactNuncarNurtb� <br /> TYPE OF WuRK ❑New Well ❑Rcpinecmcnt Well ❑Well Alteralion.Tdadiftcation ❑Other <br /> ❑Monitoring We11(s) #orwo)Lv ❑Soil Boring(s) a ofnod°P ❑Geotechnical <br /> 1 COuL-Of-Sarvice Well ❑OuuOF Service Well Renewal ❑Cross-Connection Repair <br /> ❑New Pump ❑Pump Rcplwcment ❑Pump Repair <br /> WELL CONSTRUL:I'tON <br /> Drining Method ❑Mud RoLHry ❑Air Rory ❑Auger ❑Cable Tool ❑Push Point ❑Other <br /> Proposed Well Depth ft Excavation in diameter 0 Open Bottom ❑Gravel Pack 1 Gravel Size in diameter <br /> ❑Conducror Casing in diameter ! Conductor Casing Depth 9 <br /> Well Casing Diameter in Thickness/Gauge/ASTM Scheel ❑Steel ❑Plastic ❑Stainless Steel ❑Other <br /> Grout Seal Depth B ❑Neat Cement(941b bug l5-10 gal wurer) ❑Sand Ccrnent sack mix 17 gal water <br /> ❑Bentonite(20%solids) :3Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submiecd <br /> Grout Placement Method ❑Pumpod ❑Free Fall ❑Other ❑Retardant I Accelerator(name) <br /> PEDESTAL installed By ❑Driller ❑Pump Contractor ❑ Other <br /> ❑Concrete Pedestal Dimenstooe:Width R Length fl Thick in ❑Christy Box Q Stove Pipe <br /> PUMP ❑Submersible ❑Turbine ❑Other IIP Pump Set it Standing Water Lcvcl R <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 LAW'S,AND RULES AND RECULATIONS. 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 LAWS. <br /> MINIMUM 24 HOU ADVANCE NOTICE <br /> /REQUIRED FOR INSPECTIONS p / <br /> SIGNED TITLE / J DATE <br /> S <br /> �N rq OA N <br /> E mcy <br /> ��j�/]�J�A D PA TMENT U E NLY <br /> Application Acccptcd B- 1f/L(!/1` c Date Arca Employee IDJI_4� <br /> Grout inspection By Datc El SPECIAL Well Permit <br /> CEJ-fes= dltriu[�L <br /> --rtimP nspecnon By Date_C� � Q WAIVER Re[Clved <br /> Constructed Well Depth It <br /> COMMENTS ?7 +r LtS f7 �in7 d��C <br /> PE SC Received heck# Amount Permltl <br /> Codes Info B Cash emitted Date Service Request# Invoice# Well 1D# <br /> 04 <br /> 4? <br /> EIIA�3-07-aas WELL PUMP PERMIT <br /> 1177r7gps <br />