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WELL/ PUMP PERMIT <br /> SAN JOAQUIN CODNCV ENVIRONMENTAL HEALTH DEPARTMENT NM E WERER AVE 3M1 FL-STOCK TON CA 95202 -(209)468-3020 <br /> NON-REFUNDABLE PERMIT f 11.1 •.?u'a)•h:-'.f,Q^14;141\'PI.t 11, EXPIRES 1 YEAR FRONIDATE ISSUED <br /> JOB ADDRESS _ 7!h& CITYJZIP <br /> �., r 0� <br /> CROSS STREET t ,Cy��j APN Z +Q� _,___,PARCEL SIZE _L�U.AIMA(A I7ON N <br /> OWNER NAME �f /Ak PHONL <br /> OWNER AUURLSS(( ��" CUIVISTATEIZIP <br /> CONTR4,C70R PHO <br /> CONTRA(T(1R ADDNF:SS -G'- _ CITY'J$1'ATFILIP_ <br /> SUBCONTRACION _. HONE 1k_ <br /> S('BCONTNACIIO/Rt4BDRESS - _ CITY/SIA'IE/ZIP __ <br /> . _ <br /> LICENSE O 1-57 Cfil ❑D-09 ❑Other NLMBER E%PiRATiON DATF. <br /> GEOGRAPHICAL INFORMATION". Coordinates X Y Township Range Section_ <br /> 1N TENDED USE ❑Domestic%PDvalc O ImgannNAgricultural ❑Industrial O Water Quality Monitoring ❑Soil SampbngiCharactenvation <br /> ❑Public Water System <br /> If diners.'1..0.— tae' ystem ams aM e <br /> T1 PE OtWORK ❑New Well ❑Replacement Well ❑well Altcranon/Modilicaunn ❑Otlua _. <br /> ❑Monitoriryt Wcil(s) N ofwclls ❑Soil Boring(s1 N°f heri.p ❑Gcora:hnical a or hodtyta <br /> ❑ -0f-Service Well ❑Out-Of•SCmice Well Renewal 'ro -C'unnecliou Re <br /> ew Pump ❑Pump Replacement ❑Pump Repair <br /> SVF11.(.'ONSTRL•CTIOn <br /> Drilling Method ❑Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tuul ❑Push Point ❑Other _.. <br /> Proposed Well Depth l) Iixcavaurm in diameter ❑Open Bottom ❑Gravel Pack;Gravel Size in diameter <br /> ❑Conductor Casing _in diameter I Conductor Casing Depth it <br /> Nell Casing Diameter_in Thickness/Gaugc1ASTM Sehcd_ ..... ❑Steel ❑Plastic ❑Stainless Steel ❑Other <br /> Grout Scai depth R ❑Neat Cement r94 fh!wg:t-HJ ga/ernrr) ❑Sand Cement nark mA•r 7 gal water <br /> ❑Bentonite(204,solids) ❑Manufactutcr Spec%solids_% Name ❑Spoes on I-ile ❑Specs Suhmitted <br /> Grout Placement Method ❑Puutped O Free Fali ❑Other O R tardant/Accelerator(name).__ <br /> P0E5TA1. Installed By ❑Driller ❑Pump Contractor ❑ Other <br /> ❑C crcte Pedestal Dimensions:Width 11 Length It Thick In ❑Christy Bos ❑Stove Pipe <br /> PUMP Submersible ❑Turbine 0 Other tip Pump Set_ _It Standing Water Level _ R <br /> I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION ANDv THAT THE W'OR 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 /> CLRRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COM NSATION LAWS. <br /> 'Illnl l:41'- HOUR kD\'a'N(F.NI'IC'E .(}I;1 :U FOR I��I'1:f-:Il(}�• <br /> t) <br /> TITLEDATE <br /> SIGNED <br /> D P A#t TME`1E O V <br /> Application Accepted BfL DBic C!`L1;_r/ Arca .,_ knipluyac IDN <br /> Grout Inspection By __J _- Date ` _ ❑ SPECIAL Well Permit <br /> / l ❑ W MVER Received <br /> Pump inspection By'%. � ` •_- �------ [}air -__.. _._ <br /> Constructed Nell Depth R <br /> COMMr:NTS <br /> PE Sc Received ecUl Aniount Date Permit/ <br /> Invoice N WeI11DN <br /> C Frun B Cosh Rcmht(d 1 ticrvia•Re ucar N <br /> EHD 430.-006 WPAI Pt-MP PI7XMII <br /> IYrRaat <br />