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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 301 E WEBER AVE J"FL-S-rocRTON CA 95202 -(209)468-1120 <br /> NON-REFUNDABLE PERMIT CALL.(209).953-7697 FOR INSPECT IO%S EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS -r I-I fn CmrZIP �bYl� `� > <br /> q a <br /> 05— ! o <br /> CROSS STREET �I C <br /> r J r U L�I l�+.. APN_ PARCEL SIZE LAND USF.APPLICATION R <br /> 11 y� N <br /> OWNER NAME. 0 r YYI#—Y\ �1I if i Ll PHONE <br /> OWNER ADDRESS :5n1if— <br /> I CRY/STATEIZIP <br /> CONTRACTOR AAAL7roSS WPHONE <br /> CONTRACTOR ADDRESS r/ CrrvtSTATE/ZIP �.�Uk1—!r6-r- <br /> Z <br /> L <br /> SUBCONTRACTOR PHONE_ <br /> SUBCONTRACTOR ADDRESS CITY/STATFJZIP <br /> LICENSE Q C-57 ❑C-61 0 D-09 ❑Other _ NUMBER 371 3 EXPIRATION DATE 1)—U 7 41 <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section_ l_r <br /> INTENDED USE ❑Domestic/Private ❑Imgation/Agncultural ❑Industrial ❑Water Quality Monitoring 11 Soil Sampling/Characterization <br /> ❑Public Water System <br /> If d,ff—I1-0.—. acv yatem ante --eruct umw Phoiw NumbmV_ <br /> TYPE OF WORK New Well ❑Replacement Well ❑Well Alteration/Modifiation ❑Other <br /> ❑Monitoring Well(s)_#of wells ❑Soil Bonng(s)_ a of b-.p ❑Geotechnical s of bonnys (fit <br /> ❑Out-Of--Service Well ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair I„ <br /> New Pump ❑Pump Replacement O Pump Repair <br /> WELL CONSTRUCTION <br /> Drilling Method jq Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Olhcr <br /> Proposed Well Depth 2�0� .eft Excavation 1 Z m diameter ❑Open Bottum f�Gravel Pack/Gravel Size in diameter 3 <br /> ❑Conductor Casing in diameter / Conductor Casco Depth <br /> Well Casing Diameter L in ThmkneW(jauge/ASTM Sched Z 47D r ❑Steel pJ Plastic ❑Stainless Steel ❑Other <br /> Grout Sed Depth r� ft O Neat Cement 90 lh ba /5-10 1 W,Rtrr ' <br /> Dep �_ ( K ga ) RI.Sand Cement _.tock coir/7 gal water p <br /> ❑Bentonite(200/solids) ❑Manufacturer Spec%solids % Name ❑Specs on File O Specs Submitted <br /> Grout Placement Method umped ❑Free Fall 0 Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By IRDriller ❑PumpContractoJj� ❑ Other <br /> U(Concrete Pedestal Dimensions Width `'1 9 Length fl Thick In ❑Christy Boz ❑Stove Pipe <br /> PUMP Submersible ❑Turbine ❑Other HP__!;o__Pump Set R Standing Water Level ft <br /> 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUI.N 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 IV COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> �//�, M1IINIMUM 21 HOUR ADVANCE NOTICE RREQL IRED FOR INSPECTIONS !� <br /> SIGNED L7 / Z/� _ _ TITLE V/t.y1-Fi>` DATE <br /> n <br /> �j Ila <br /> r 4 <br /> SiN <br /> i <br /> jr <br /> (DAIPARTMENT U E O L Y <br /> Appliaution Accepted B Qi Ar �7" — TmpToy«IDM Iq <br /> Grout Inspection By Dau ��—?'.S� L ❑ SPECIAL Well Permit <br /> Pump Inspection y Dau ����(. ❑ WAIVER Received <br /> Constructed Well Depth n <br /> COMMENTS _. <br /> PE SC Received Q004,111f, Amount Dale Permit/ Invoice0 WellIDM <br /> Codes I1210 By Cash Remitted Service R nest M <br /> Y� C� 3 z S �> () v"!" 5 <br /> 0 1311� S() \ Z us <br /> ERU/1 0.006 WELL PUMP PERMIT <br /> 117005 <br />