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'WELL/PUMP PERMIT <br /> -` SMI JOAOUIN COUNTY ENVIRONMENTAL I 4 DEPARTMENT 600 EAST MAIN STR rN ToCKTON CA9S262 <br /> i NON-REFUNDABLE PERMIT CALLQ20/�9)953-76`971FOR <br /> �INSPECTIONS LfE�X/rAREESS�1/�YEAR FRO A` 9 UE PED \V/ <br /> rl <br /> JOB ADDRESS 1/301"4"'/`f�55 5- /TI/G/' W�(. CITYJIrP { ///r` 7Z!4 „ Q,53 b_ <br /> ! O D-8 > <br /> CROSS STREET_ R D r L 1 ICCJD'T't�_APN A-O PARCEL$kZE G-'OCJ LAND EJ9E APPLICA710N# 0 <br /> a <br /> OWNER NAME PSE re <br /> OMrNER AADRE55 �j [' CITYISTATEIZIP <br /> CONTRACTOR �tl r _"_•.Q,_-_�-NQ�Se)X f'r .S-F-Q C,! fAf<- PHONE 3G —3 <br /> CONTRACTOR AnoRrss O Z /V `R <br /> SUBCONTRACTOR PHONE <br /> SU=NTRACTOR ADDRESS CITYISTTAATEPLIP <br /> LICENSE 4.57 D C-61 O ll L Other NUMBER !� EXPIRATION DATE a Q <br /> GEOGRAPHICAL INFORMATION: Coordinates Y Township_ Rangel Section <br /> INTENDED Use D DomesWJPrivate D InlgatioNAgricultural ❑Industrial D Water Quality Monitoring Sal Sam plinglCharacterization <br /> D Public Water System <br /> Ifdltterentfrom Owner. water by5MM Nafre I.OrpLact NaMD or ervie Narftr <br /> TYPE OF WORK q New Well 0 Replacement Well ❑Well AlterationlModification ❑Other <br /> �1 of borings Ad <br /> ❑Monitoring Wall(s) #of urelLs 7 Soll t3oring(s) eotechnipl $ <br /> ❑Out-Of-Service Well ❑Out-Of-Service Weil Renewal D CrOSS-Connection Repair Cyd <br /> 0 New Pump ❑Pump Replacement DEyMp Repair d <br /> WELL CONDUCTION 1 <br /> Drilling Method ❑Mud Rotary ❑Air Rotary Auger ❑Cable Tool ❑Push Point ❑ Other <br /> Rroposed Welt Depth 20-4 It Excavation in diameter U Open Bottom ❑Gravel PaWGravel Size in diameter <br /> ❑Conductor Casing in diameter f Conductor Casing Depth ft <br /> Well Casing Diameter In ThichnesslGauge/ASTM Sehed ❑Steel ❑Plastic ❑Stainless Steel D Other <br /> Grout Seal Depth ft Neat Cement(94 Ib bagr5 10 gat water) ❑Sand Cement Sack mixt7 gal water <br /> ❑Bentonite(20%soFds) _ <br /> Grout Placement Method U Pumped ❑Free Fall D Other U Retardant I Accelerator(name) <br /> PEDESTAL Installed By ❑Driller 0 Pump Contractor ❑ Other <br /> ❑Concrete Pedestal Dimensions:Width ft Length ft Thick in ❑ChristyBox n Stove Pipe <br /> Pules ❑SubmerslbleU Turbine D Other HP Pump Set ft Standing Water Level R <br /> I 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. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT t AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> NIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOyR^INSPECT=ONS <br /> sIGNE TriLE e e " . DATE-2--31:29_ <br /> {� s <br /> U la1 V <br /> t Z - fn <br /> kvm 1fJOdflly J <br /> Q <br /> " JO C. fey O <br /> 1110 <br /> 4 OV0a7rda 31JIDVd NOINO <br /> - ....a� � �_ c•.-- _�.-rte• y _. - _- —. — — <br /> OEPART MENT...USE ONLY <br /> Application Accepted By Date 3 'd Area Employee 100 40 <br /> Grout Inspection By Date C SPECIAL Well Permit <br /> Pump Inspection By Date © WAIVER Deceived <br /> Salt Boring Inspection By to 3 Cor lcted Well depth ft <br /> COMMEN <br /> PE SC Received hes Amount Date Pormltl Invoice# WeII lD# <br /> Codes Info B Remitted Service Re uest# <br /> 3ma si cSyK <br /> EH015-06 WELL/PUMP PERMIT <br /> srleepr <br /> '7 <br />