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9i9ELUFU6l P PER�IliOU <br /> SAN JOAQUIN COUHTY ENVIRONMENTAL NEALTi'i DEPT '1860 East Hazelion Avenue-S TOCICrON CA 95205-6232-(209)460-3420 //' <br /> 01.JFI-F:13FUNUA6LE PERMIT GALL(209)953-7697 FOR 114SPECTI❑NS GEXPPII,REES- 'I YEAR FROM DATE ISSUED <br /> I.IoenDDnESS 5s e)1Crrr21P <br /> CK033 STREET__��J y^T— N TARCCL SUM-/ �IJIND USE APPLICATION# m <br /> OWNER I IAmi: /�'7 �yyl, � � PHONE <br /> OWNER:'.DDRE55 CITYI$TATEIZIP , - /✓ z5 <br /> CONTRACTOR `"F �/y pf/�PHONE <br /> CONTRACTOR ADDRESS l20 l�Uil...�o,��� CIIIISTATFIZIP� <br /> e � <br /> SUBCONTRACTOR S /L- �/Ij PHONE <br /> SUBCONTRACTOR.ADDRESS CITY/STATE/ZIP <br /> LICF-NSE C-57 C-(31 O D-00 ❑Other NUMBER EXPIRATION DATE <br /> GEOGRAPHICAL INFORM•ATIOH: Coordinate--X Y Township— Range_ Section_ <br /> INTENDED USE 0 Domestic/Private VInigalion/Agricultural 0 Industrial 0 Water Quality Monitoring 0 Soil Sampling/Characl I lyk <br /> D Public Water Sy mm <br /> Il dilferoni frmoawn .. nor y;em arae �onlac amo or ono um cr �Jh� <br /> 'i YPE OF TJORIc New Well 0 Replacement Well 0 Well Alteration/Modification 0 Other �+ <br /> S of borings i! hn <br /> 0 Monitoring Well(s) #of wells 0 Soil Boring(s) 0 Geotechnical Sq,t,_. n <br /> 0 Out-Of-Service Well 0 Out-Of-Service Well Renewal 0 Cross-Connection Repair E gQU7 J <br /> Naw Pum 0 Pump Replacement 0 Pump Repair 0 Raise Well Casingy�GRONaN�CO <br /> 'P115K__ <br /> rELL CONSTR TION pA�TM'9C <br /> rllling i'lethod`¢I Mud Rotary D Air Rotary ❑Auger O Cable Tool O Push Point ❑ Other FNS <br /> roposod Woll Depth� ft E(cavation_1in diameter 0 Open Bottom ravel Pack/Gravel Size_ in diameter <br /> 0 Conductor Casing In diameter / Conductor Casing Depth It <br /> iJell Casing Diameter_in Thicl(ness/Gauge/ASTM Sched GL Z 0 Steel NPlasuc D Stainless Steel D Other <br /> Grout Seal Depth 15D fl 0 Neat Cement(94 lb bag15-10 gal water) D Sand Cement sack mbJ7 gal water <br /> Vbentonito(20%solids) 0 Other <br /> i•'i'ou"Placemen'Me'hod,VPumped 0 Free Pall 0 Other 0 Retardant/Accelerator(name) <br /> r <br /> PEDESTAL Installed By 0 Driller D Pump Conlrac or,( O Other <br /> D Concrete Pedes^-•)Dimensions'Width :Ll9ength it Thick in O Christy Box 0 Stove Pipe - <br /> PUMP )gtLbmersiblc0 Turbine O Other IIP Pump Set ft 'Standing Water Level -•R <br /> f-IERECY CERTIFY"THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORTS WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNT`(ORDINANCES, STATE LAWS, AND RULES ARID REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTI`JE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND ThIATJ AM IN COMPLIANCE WITFI ALL <br /> `NORI(ERS COMPENSATION LAWS. <br /> ys <br /> /` 'G/ i� I LOUR ADVANCE NOTICE REQUIRED FOR INSPCC'flOfV5 <br /> SIGNED �f ��2 TrrLe Z /f? DAT O 2 <br /> TFn <br /> i <br /> IN <br /> OEPARTPnEWT use ONLY <br /> Application Accepted By Dato Area / Employee IDIJ 5� Q ^^M <br /> Grout Inspection By Date r SPECIAL Well Permit <br /> Pump Inspection By Date_ WAIVER Received <br /> Soil Boring Inspection By Date Consirucied Well Depth ft 1^ ,O �AfI� <br /> COMMENTS U ✓J <br /> PE SC Received Cho Amount Date Permi(! Invoice#? WeIIID!? ,n J <br /> Codos InrO Dv Cash Remitted Service Request# A' / ' . (//�//�►r� <br /> WELL RUMP PERMIT <br /> EH 43-05 <br /> WOMB <br />