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_�]RUM <br /> SAN JOAQUIN COUNr,,ENVIRONMENTAL HEALTH DEPT 9868 East Hazelton Avenue-STOCICtON CA 95205-6232 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED <br /> JOB ADDRESS . v Lam- /"lam CITY/ZIP 'v� m <br /> CROSS STREET ! 0 1.%PN U V! ARCEL SIZE_,,.�LAND USE/APPPLICA IONCn <br /> # <br /> OWNER I IA IE / yl.� ' �� PHONE -4b3- 3~3 O T N <br /> OWNER. DDRESS CITY/STATE/ZIP <br /> CONTRACTOR 1 <br /> ''<,, �./��//�� �`1 5� PHONE <br /> �j���/—�G�`f� <br /> CONTRACTOR ADDRESS �/ !�� !///�L'�-Q �s�� CITY/STATE/sIP ► .1 <br /> /I <br /> SUBCONTRACTOR �— PHONE �— <br /> SUBCONTRACTOR ADDRESS CITY/QSTATEIZIP <br /> LICENSE .WPC-57 -GI o D-09 ❑ Other_ Numauf? ` TAIM/c/5 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 System Name Contact Name or Phone Number <br /> TYPE Or WORK ❑ New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other <br /> ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) 9 of borings ❑ Geotechnical 4 of borings <br /> ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> O New PUrnp WtlurnpReplacement ❑ Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Wlethod ❑ Mud Rotary ❑Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other <br /> Proposed Well Depth it 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/Gauge/ASTM Sched ❑ Steel ❑ Plastic ❑ Stainless Steel D Other <br /> GI'011t Seal Depth ft ❑ Neat Cement(94 Ib bag/5-10 gal water) ❑ Sand Cement sack mix17 gal water <br /> ❑ Bentonite(20%solids) ❑ Other <br /> Grout Placement Method ❑ Purnped ❑ Free t=all ❑ Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller ❑ Pump Contractor- ❑ Other <br /> ❑ Concrete Pedestal Dimensions:Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe <br /> , <br /> PUMP Submersible❑ Turbine ❑ Other I-IP Pump Set h `standing Water Level s <br /> I HERESY CEF:I IFY 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 t EI i:; i ION LAWS. .y� <br /> M 3d NOUR ADVANCE NOTICE REqyIRED FOR INSPECTIONS <br /> SIGNED TITLE IG; C DATE <br /> s <br /> -- ` <br /> h Q <br /> ti M <br /> R <br /> ? ARTMENT USE ONLY <br /> Application Accepted By Date Area mployee ID'# <br /> Grout Inspection By Date ECTAL Well Permit <br /> Ps�iw-rv)n Purnp Inspection Byr Date \O/ I I /I IC1 WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received heck#/ Amount Date Permit/ Invoice# We <br /> ID!!- <br /> Codes Info By as Remitted Service Reoluest <br /> o (SR�� —7 'l o o WF00 4W 78 <br /> EIiD 43-06 WELL/PUMP PERMIT <br /> 8!04/08 <br />