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WELL 1 PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HL-1-11 DEPARTMENT 31M E WEBER AVE 3e°! 2� 20 <br /> NON-REFUNDABLE PERMIT CALL. 209 953-7697 FOR[NtiPECTION% EX ATE UED <br /> ��y �lSa3/ <br /> !w� CITY1ZIp <br /> JDB ADDRESS V t/" -- d <br /> /J L APN I9�0'L V-Q PARCEL SIZE ,LAND USE APPLICATION>1 <br /> CROSS STREET._AirDDr 1 Wim— phi <br /> OWNERNAME P/HONNE <br /> OWNER ADDRESS <br /> ®� E /�+"• .,Q CITY/STATFalP '(.-t <br /> CONTRACTOR �C'�p .yOI`�`'�� /'k�Lr T�C- __ PHONE -J 7-278/ <br /> CONTRACTOR ADDRESS (/����� 1'�1I/� YVr�^/ CtiYISTATPJZIP� �� <br /> SUBCONTRACTOR, )-n{ PHONE <br /> G <br /> SUDCOI4TRACTOR ADDRESS CITYfSTATE/ZIP <br /> LICENSE 0 C-57 CIC-61 17 D-09 ❑Other NUMBER ExPIRATtoN DATE w,a <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section <br /> [NTENDEDJJSE 13 DomesticIrrivale 0 Irrigation/Agticultural O Industrial 0 Warer Quality Monitoring 0 Soil Sampling/Characterization <br /> 0 Public Water System <br /> Hdif—I fmm r aur Tsmm ams -Lt ams or ne um r <br /> TYPE OP WORK O New Well 0 Replacement Well 0 Well AturationlModification 0 Other <br /> eofhorinp J21mGeolechnical pZ _-s oft"*W <br /> ❑Monitoring Wells) #of wiles O Soil Borings} <br /> 0 Out-0SServiu Well 17 Oul-0f-Service Well Renewal O Cross-Connection Repair <br /> 0 New Pum 0 PuroD Replacement 0 Pu R it <br /> WELL CONSTBt1Cr10N <br /> Drllling Method 0 Mud Rotary 0 Air Rotary )Auger 0 Cable Too) 0 Push Point ❑Other <br /> Proposed Well Depth I�Q ft Excavation_ 9 in diameter 13 Open Bottom 13 Gravel Pack 1 Gravel Size in diameter <br /> O Conductor Casing in diameter 1 Conductor Casing Depth - It <br /> Well Casing Diameter_in ThiekncsslGaugdASTM Sched 0 Steel ❑Plastic 0 Stainless Steel 0 Other <br /> Grout Seal Depth ft Mhleat Cement(94 1b bag/5-169al worm)i r61Al 13 Sand Cement sack mix 17 gal water <br /> 0 Bentonite(20%solids) 0 Manufacturer Spec%solids._% Name 1A AiV�- 0 Specs on File ❑Specs Submitted <br /> Grout Placement Method 'OPumped 0 Free Fall O other 0 Retardant I Accelerator(name) <br /> PEDESIAL Installed By 0 Driller 0 Pump Contractor O Other <br /> 0 Concrete Pedestal Dimensions:Width It Length ft Thick in 0 Christy Box 0 Stove Pipe <br /> E PUMP O Submersible ❑Turbiee 0 Other HP Pump Set fl Standing Water Level ft <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 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 /> MIN!W HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> SIGNED _ -- TrrLE ` �I--' tDATE S O <br /> E <br /> I It Ty <br /> I <br /> t O <br /> t <br /> N <br /> M � C <br /> H E <br /> --- DE ARTMEN'r USE ONLY <br /> 9 <br /> Application Accepted B Date Arca Employee ID#T✓l� - <br /> i Grout Inspection Dau O ❑ SPECIAL Well Permit [ <br /> �M,�101 <br /> Pump Inspection By Dau Q WAIVER Received <br /> E Constructed Well Depth R <br /> COMMENTS <br /> PE SC Received C Amount Dale Permit/ Invoice Is Well IDN <br /> Codes Into H Cash Remitted Service R vert# <br /> OF <br /> 90 zo9s3 D�, �a <br /> WELL PUMP PERMIT <br /> EHD O-024M <br /> + MW2005 <br /> 7 <br />