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WA LLIPUMP PEERMff <br /> SAN JOAQUIN CoLINTY ENVIRONMENTAL HEALTH DEPT 9868 East Hazelton Avenue-STOCI'CTON CA 95205-6232 - (209)468-3424 U <br /> NON-REFUNDABLE PERMIT CALL(209"153-7697 FOR INSPECTIONS EXPIRES 11 YEAR FROM DATE ISSUED <br /> rn <br /> /� kAl l e— C' 9S3b m <br /> 906 ADDRESS 1 f '16q 11"3 L �WA!'J S Crn/�ItP V a '� �9 <br /> CROSS STREET lJA I� �/�ta�If-AA � f Af,11 ALO 1- Z46 SSL PARCEL SIZE l V•S LAND USE A[P�PLICIA71 ON# m <br /> 0W—R1%9t f A �W n_ 1 if, PHONE �'/�`7 - r Sol <br /> s n �' <br /> ©INNNER:-.DDRESS 4 WO CA r Cl-r,/STATE/ZIP rAesvt)vt,4,"bf '1574 <br /> CONTRACTOR mgm•c�l a bV,it I 1 V%f J Eke • �/�PHONE .5.57-Z- 1112-9 <br /> CONTRACTOR ADDRESS t A I6crS 1�-�l CIT Y/STATEIZIP M.'/'eS-/V co, <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE C-57 ❑ C-611 ❑ D-09 ❑ Other NUMBER [� L EXPIRATION DATE <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 Systom Name Contact Name or Phone Number <br /> TYPE OF WORKNew Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other <br /> ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings ❑ Geotechnical #of borings <br /> ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal 0 Cross-Connection Repair <br /> 0 New PUrnp 0 Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling MethodxMud Rotary .0 Air Rotary ❑ Auger ❑ Gable Tool 0 Push Point ❑ Other <br /> Proposed Well Depth02SO it Excavation 0 -- in diameter ❑ Open Bottom ' lCGravel Pack/Gravel Size in diameter <br /> ❑ Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter Thickness/Gauge/ASTM Sched '1450 ❑ Steel XIastic ❑ Stainless Steel ❑ Other <br /> Grout Seal Depth /O ft ❑ Neat Cement(94 lb bag/5-10 gal water) ❑ Sand Cement sack m1x17 gat water <br /> )KBento ' (20%solids) ❑ Other <br /> Grout Placement Method umped ❑ Free Fall 0 Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller Wump Contractor ❑ Other <br /> ❑ Concrete Pedestal Dimensions:Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe <br /> PUMP 0 Submersible❑ Turbine 0 Other HP Pump Set 'ft `Standing Water Level ft <br /> I HEREBY CEIRTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDINANCES, STAVE LAWS, AND RULES AND REGULAIIONS. 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 COMPENSAI ION LAWS. <br /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED I OR INSPECTIONS 9 /Q <br /> SIGNED TITLE QP-VK-#-/ DATE I r(~ <br /> 000, <br /> t7 <br /> I IU <br /> -- UI C u <br /> -- — IR N <br /> EPAR T MENT USE wMdY <br /> AlAld <br /> Application Accepted By Date � � Area � � Employee ID#�i�WM <br /> Grout Inspection By Date l J t� SPECIAL WeII Permit <br /> Pump Inspection By Date WAIVER Received _ <br /> Soil Boring Inspection By Date Constructed Well Depth G e�� ft <br /> COMMENTS r <br /> :5124140 Al- AZ G w4c:s4loc �n� <br /> PE SC Received Chocicrtl Amount Permit/ <br /> Codes Info By Cash Remitted Date Service Request;§`• Invoice# Well ID# <br /> 2 � 92 W14 <br /> EHD 43-06 WELL/PUMP PERMIT <br /> 8/04/08 <br />