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rl <br /> j'` WELL / PUMP PERMIT SCft <br /> AWat74 Q ao <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH D TMENT 304 E TON CA 95202 - (209)468-3424 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED <br /> JOB ADDRESS l"t L- i 'Il� ! CITY/ZiP i Vl�Q�]r'�,- ., 5' <br /> ' G— <br /> ET 1PARCELSIZEL�_CROSS STRELAND <br /> USE APPLICATION f# 70 <br /> OWNER NAME PHO y <br /> OWNER ADDRESS CITY/STATE/ZIP <br /> CONTRACTOR ! [W C{� l�ll �6�—� U�L PHONE Q04L t4� <br /> CONTRACTOR ADDRESS7S Y. tJ rP _ CITYISTATE/ZIP <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP J �f <br /> LICENSE -57 ❑C-61 ❑D-09 Cl Other NUMBER EXPIRATION DATE 1C9/ 1/? L /© <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE ❑Domestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring Soil Sampling/Characterization <br /> ❑Public Water System <br /> If different from owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK ❑New Weil ❑Replacement Well ❑Well Alteration/Modification ❑Other <br /> ❑Monitoring Well(s) #of wells ❑Soil Boring(s) 4 of borings O�Geotechnical of borings <br /> ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> ❑New Pump ❑Pump Replacement ❑Pump Repair } <br /> WELL CONSTRUE f ION <br /> Drilling Method ❑Mud Rotary ❑Air Rotary YLAuger ❑Cable Tool ❑Push Point ❑Other <br /> Proposed Weil Depth ].T -Z4 ft Excavation a-117 J in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter <br /> ❑Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge)ASTM Sched ❑Steel ❑Plastic ❑Stainless Steel ❑Other <br /> Grout Seal Depth ft ❑Neat Cement(941b bag 15-10 gal wager) ` <br /> l,J❑Sand Cement sack mix 17 gal water <br /> ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name i�4—. tr�,� 1 ❑Specs on File ❑Specs Submitted <br /> Grout Placement Method ❑Pumped ❑Free Fall ❑Other ❑Retardant 1 Accelerator{name <br /> PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑ Other <br /> ❑Concrete Pedestal Dimensions:Width ft Length ft Thick in ❑Christy Boz ❑Stove Pipe <br /> PUMP ❑Submersible ❑Turbine ❑Other HP Pump Set ft Standing Water Level ft <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. 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 /> III MUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS /} <br /> SIGNED �`" ' 1]�� TITLE ' s DATE V <br /> 1" <br /> a S, <br /> A UI <br /> I ILE <br /> k <br /> el <br /> 7' r1l 'E N T 'IS <br /> E ONLY �Z/ <br /> A plication Accepted By Date Area Employee ID# <br /> meant Inspection B f G'' Date G' ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#I Amount Date Permit/ Invoice#] Weil IDYL <br /> Codes Info By Cash Remitted Service Request 4' <br /> GD tS (-r 12~[ y `Z 4 b ' <br /> FHD.41-02-906 _ .. __ WELL PUMP PERMIT <br /> 1/27)2005 - <br />