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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-S rocI(TON CA 95205 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 09)953-76917 FO/R� INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESSvO 'v ���!"r 7`►� CIT`/ZIP r [ m <br /> D <br /> CROSS STREET C0 L/ ` �d _ APN DZI 0-72-1�7 PARCEL SIZE /y LAND USE APPLICATION# cn <br /> (J <br /> OWNER NAME _ «I� � C V hZN PHONE�OO0 / N <br /> OWNER ADDRESS�'� C��a �-l0 hi_ / z� CITY/STATE/ZIP1,/j (Z <br /> CONTRACTOR `]p A G!0t­� .n-/ lr I` r __ PHONE32 y 7 7 l <br /> CONTRACTOR ADDRESS (.� j�{� CITY/STATE/ZIP_C—(/ <br /> SUBCONTRACTORS PHONE L? 31 La <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE -57 C-61 D-09 Other _ NUMBER /J�'- EXPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X 77) ©C? R, ig Township - Range Section <br /> INTENDED USE LJ 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 umber <br /> TYPE OF WORK %-I New Well Replacement Well ❑ Well Alteration/Modification ❑ Other <br /> ❑ MonitoringWells #of wells ❑ Soil Boring(s)s #of borings Yedpyin _.-yr <br /> O gO .__. Geotechnical ��ss1/�r�p <br /> ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal 7 Cross-Connection Repair Oct <br /> ,VNew Pum Pum Replacement n Pum Repair I 1 Raise Well CasingUC. <br /> WELL CONSTRUCTION SANS <br /> Drilling MethoqXMud Rotary I Air Rotary Auger Fl Cable Tool Push Point 1 1 Other FN�AQU/N <br /> Proposed Well Depth Ejo ft Excavation . in diameter Open Bottom + Si <br /> ravel Pack/Gravel z�6'->'p Aiti diameter <br /> Conductor Casing--_ - in diameter / Conductor Casing Depth ft ENT <br /> Well Casing Diameter IF-- in Thickness/Gauge/ASTM Sched "Lau -1 Steel , Plastic ❑ Stainless Steel Other <br /> Grout Seal Depth SJ ft Neat Cement(94 lb bag/5-10 gal water) 1)6and Cement /i): -3 sack mix/7 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method -<umped Free Fall 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 /> PUMP Submersible Turbine Other HP EQ Pump Set ft Standing Water Level ft <br /> I HEREBY CERTIFY 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 COMPENSATION LAWS. <br /> MINIMUM 224 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209)953-7697 <br /> SIGNED �E�C a� .. TITLE O(!).F,tl _ _ - DATE <br /> 0 <br /> —41——— <br /> r <br /> E�TMENT USE LY <br /> Application Accepted By Date 4r?a— Emplovee ID <br /> Grout Inspection By _ del _ Date Jfii( CJ PECIAL Well Permit <br /> Pump Inspection By �� Date IG�14f �� F1 WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Amount Date Permit/ Invoice# Well ID# <br /> Codes Info By Cash Remitted Service Request# <br /> dl, l 478 zv i� P�a 5 t� <br /> cr SO aE Zq,)- - UAJ <br /> EHD 43-06 WELL/PUMP PERMIT <br /> 4/30/12 <br />