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WELL 1 PUMP PERMIT SCANNED'` <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH L -..ARTMENT 304E WEBEh- ;E CANON CA 95202 - 209 468-3420 <br /> 3 ( ) <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES l YEAR FROM DATE ISSUED <br /> JOB ADDRESS CrI'Y/ZIP q005 <br /> a <br /> CROSS STREET VdvtX <br /> N d I 7 `I3 PARCEL SIZE LAND USE APPLICATION# <br /> OWNER NAME <br /> PHONE <br /> OWNER ADDRESS C[TYlSTATEIZIP <br /> �5aaz 164 `— <br /> CONTRACTOR PHONE <br /> CONTRACTOR ADDRESS CITY/STATEIZIP y n . ,A 4 <br /> SUBCONTRACTOR _ PRONE <br /> r� <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE -57 ❑C-61 11 D-09 ❑Other NumBE EXPIRATION DATE <br /> GEOCRAPH CAL INFORMATION: Coordinates X Y Township Range Section <br /> IN N ISE omestic/Private ❑Irrigation/Agricultural 0 Industrial ❑Water Quality Monitoring Cl Soil Sampling/Characte.rization <br /> Public Water System <br /> If different from owner; Water System Name Contoct Name or Phone um Fr <br /> TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Aiteration/Modification ❑Other <br /> {` #ofborings #of borings <br /> ❑Monitoring Well(s) #of wells 13 Soil Boring(s) ❑Geotechnical <br /> C]Out-Of-Service e ❑Out-Of-Service Well Renewal ©Cross-Connection Repair <br /> Put Pu <br /> ❑New Pum Replacement ❑Pump Repair <br /> WELL--C-ONSTRUC[ON <br /> Drilling Method ❑Mud Rotary ❑Air Rotary 0 Auger ❑Cable Tool ❑Push Point ❑Other <br /> Proposed Well Depth ft Excavation 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/GaugeJASTM Schell 13 Steel ❑Plastic ❑Stainless Steel Cl Other {� <br /> Grout Seal Depth ft 0 Neat Cement(94!b bag/5-10 gal water) ❑Sand Cement sack mix 17 gal water <br /> 0 Bentonite(201/o solids) ❑Manufacturer Spec%solids % Name ❑Specs on File" ❑Specs Submitted <br /> .Grout Placement Method ❑Pumped ❑Free Fall ❑Other ❑Retardant I Accelerator(name) <br /> 1 <br /> PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑ Other <br /> ❑Concrete Pedestal Dimensions:Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe <br /> PUMP Submersible ❑Turbine ❑Other HP ZQ Pump Set ft Standing Water Level ft <br /> I HEREBY CE T Y 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 I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> 1 24 OUR ADVANCE NOTIC REQUIRID FOR INSPECTIONS <br /> SIGNED / TITL DATE <br /> 1 <br /> 1xv 'ed <br /> Sw <br /> i <br /> i <br /> 0 <br /> i <br /> - <br /> DE PART'MENT USE ONLY �Y <br /> Application Accepted By Date - Area Employee IDN � t <br /> Grout Inspection By Date ❑ SPECIAL Well Permit 99 <br /> Pump Inspection By Date dS ❑ WAIVER Received <br /> Constructed Well Depth it J <br /> COMMENTS CC� 7f_c�nJ V <br /> PE SC Received XbecW Amount p to Permit/ Invoice# Well IDN <br /> Codes Info Cash Remitted Service Re uest# <br /> EHD 43-02-006 WELL PUMP PERMIT <br /> Imnoo5 <br />