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14;0 S 4A <br /> WELUPUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCK 1`13N CA 95205-(209)460.1420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JosAODRm � � CITYMP� \&11 L <br /> U9EAPPLCATON#CROSAPNQD1 "j/QQ~�tQ PARCEL S`&M- LANO <br /> OWNER NAME (-17rf zalez— (C�I f<1ca• Nym <br /> PHONE�• 1+ �/ •�°• <br /> OWNER AOORESS �1 J �( CTTYISTATFILP C_� Q <br /> CONTRACTOR hen IL"� Iall!"1 f �fmps, ) 4&- 2t •' <br /> CONTRACTOR ADDRESS A5?i /Tl• Ll n cti ll WIL CrTY1STAT60P„r a If CA 9'SIL'•3.,L <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR Aome3S CRY/S�AT1t�LP^ <br /> LICENSE 7 n G-61 1^D-09 F1 Other NUMBER J•�0 F j E7rP mroN DATE <br /> GEOGRAPMCAL INFORRATWR: Coordinates X Y Township_ Range Section_ <br /> INT*MFD USE 'DomasliciPrivate C IRigatbNAgdculturM 0 Industrial ❑Water Quality Monitoring 7 Soil SamplinglCharacterirauon <br /> L Public Water System <br /> If ellft w I from Owner water.%wem Name c4mzjNafNorrwne NOW <br /> TYPE OF WORK�4Aew Well 7 Replacement Well C Well Alle2tion/ModNiptian G Other_ _ <br /> /..Monitoring WeII(s) #ofwalls r-Soil Sonrg(s) Mo10c°ngs n Geotechnical_ °rb0l0a` <br /> Out-cpservice Well C Out-Of-Service Well Renevrai n Cross-Connection Repair <br /> •New Pum l Pum Replacement C Pum Repair 3 Rake Well Casio <br /> cno <br /> WELL CONaTRUl <br /> Drilling Method 0 Mud 4tan�y _Alr Rotary --Auger ,40able Tool ❑Push P ' 7 Other <br /> Proposed Well Depth JC' ft Excavation in diameter pen Banom 0 Gravel PacWGravel Size in diameter <br /> 0 Conductor Casing in diameter / Conductor Casing Depth ft <br /> Wen Casing Diameter_in Thickness/Gauga/ASTM Schell _Steel +t PlaWie n Stalnless Steel r OCler <br /> Grout Sod Depth_,,/ �' ft rl Neat Cement(941b beg/5.10 gat water) 416nd Cement z. sock mbr17 gal water <br /> G Bentof*e(2Q%so1 ds) 0 01her <br /> Groat Placement Method ped 7 Free Fag 0 Other =Retardent/Accderstor(name) <br /> PEDESTAL Installed By 0-Driller in Pump Contractor n Other <br /> I Concrete Pedestal nDimenslons:WIdth -ft Length ft Thick in n Christy Box -i Stove Pipe <br /> PUMP SubmensjbieU Turbine 0 Other__ HP Pump Set - It Standing Water Level ^ R <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SANS <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 COMPENCI�LAWS. <br /> MIN! UR ADYA CE NO_TICE REQUIRED FOINSPECTIONS-PLEASE CALL(209)953.7697 <br /> $I , r TIi1P DATE �. / /z <br /> AT <br /> r� <br /> PAYMENT <br /> RECENED <br /> JUN 2 9 201rt7l fl I I <br /> so'sEHVIRONMENTAL y <br /> HEALTH DEPARF <br /> €P RTME SENLY <br /> Application Accepted By da 1 Are _ Employee ID# L <br /> Grout Inspection elfA,^ -t i. , r Date 7 G SPECIAL Well Permit <br /> Pump Inspection Byi'rr�r �/ Date 112 0 WAIVER Recelved <br /> Soil Boom Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE Sc r <br /> Received Cheek#f Amount tba Perm1V invoice# Well IDN <br /> Codas Info Cath RtmiCW Service RequestS <br /> fU6 �Sc..- '� to S <br /> zQ1 N51Y <br /> 655 '' U-753. <br /> WELL PUMP vQtNrT <br /> eHQ,aee �L3�� <br /> uxnz <br />