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WELL/PUMP PERMIT <br /> SAN JOAQUEN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3"FL-STOCK <br /> TON CA 95202 - (209)"B-3420 <br /> • NON-REFUNDABLE PERMIT CALL 209 953-7697 F012 INSPECTION!; EXPIRES I YEAR FROM DATE ISSUED 1 y <br /> R'(1,` Mok('�LugNC IR-NOL NrXi '(s OMgNOt C1rr2EP LI E mEr4-1c5 ii <br /> Joe ADDRESS '2j �f <br /> ISN HA uir�� 4� Nwy IZ APN0ZJ"_ZIP- 0I �PARCELSIZIE 6)5LANDUSE APPLICATION <br /> H <br /> j" <br /> PHONE i <br /> OWNER NAME " R ( <br /> CrrY/STATE/L[ <br /> OWNER ADDRESS (. I / <br /> A Ji.IN 1 fV O <br /> �7�, P`H/ONE /� 9-16- 1 G.//� <br /> l.7� 1 I'j S J j l; (0`7 CrrY/STATE2ff'O I (.F'�r` I' CA ,l / �/�_� <br /> CONTRA CTOR ADDRESS (� /J ` _ <br /> SUBCONTRACTOR _ 12s L 1C.i' `)L'1/I ( 1 1 PHONE �31 <br /> SUBCONTRACTOR ADDRESS ✓ I Vy C S I C'l��I I IDL- R V '166710 <br /> /C^rrry/STTATUZIP W LC ✓ C ✓" r <br /> LICENSE /-57 ❑C-61 ❑D-09 ❑Other NUMBER I V "7 1 0 EXPIRATION DATE <br /> y <br /> GEOGRAPHICAL INFORMATION: Coordinates )C Section_ <br /> '- <br /> Township_ Range <br /> INTENDED USE ❑Domestic/Private ❑IrrigatiorJAgricultural ❑Industrial ❑Water Quality Monitoring oil Sampling/Characieru,ation <br /> ❑Public Water System o t,ci ,mc a um <br /> If different from O—er. <br /> TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteratior✓tvfodifiwtM of bonnps ❑Geotechnical ion ❑Other aof � <br /> ❑Monitoring Well(s) Hof wells Soil Boring(s)_! <br /> ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> ❑New Pum2 Pump Replacement ❑Pume Repair <br /> WELL CONSTRUC-nON <br /> Drilling Method ❑Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Other <br /> Proposed Well Depth „2_S—100 fl Excavation in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter <br /> ❑Conductor Casing in diameter / Conductor Casing Depth fl ('n <br /> Well Casing Diametcr�—� in Thickness/Gauge/ASTM Sched ❑�Steel Cl Plastic EI Stainless Steel ❑Other � <br /> Grout Seal Depth H .Neat Cement(➢a/b bag .i-/0 ga/wafer) f T G-w❑Sand Cerr/ent sock mix/7 gal water <br /> ❑S on File ❑Specs Submitted N <br /> ❑Bentonite(20%solids) ❑Manufacturer Spec%solids_% Name Pe <br /> '�".�'F'`t-c'E- ❑Retardant/Accelerator(name) <br /> Grout Placement Method ❑Pumpcd ❑Frec Fall .Other � <br /> PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑ Other <br /> El Concrete Pedestal Dimensions:Width fl Length k Thick m ❑Christy Boa ❑Stove Pipe <br /> I <br /> ppm ❑Submersible ❑Turbine ❑Other HP Pump Set fi Standing Water Level <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN 1'"( <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS,AND RULES AND REGULATIONS. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> v T IVNI 24 HOUR.ADVANCE:NO"rICE REQUIRED FOR INSPFC'r10�S <br /> TITLE 1 Y2-t/�b- �`✓�A M A C L-R-nl DATE � 0'I O- S <br /> SIGNED <br /> PAYMENT <br /> DECEIVED <br /> JUL 2 6 2005 <br /> N JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> EALTH DEPARTMENT <br /> D E P A RTMENT USE ONLY <br /> L�Y �7 / <br /> ( Q, l I C) Area Employee ID# <br /> Application Accepted By Date I / <br /> Grout Inspection By <br /> Dale 4 D ❑ SPECIAL WeII Permit <br /> Pump Inspection By <br /> Date ❑ WAIVER Received <br /> Constructed Well Depth It <br /> COMMENTS <br /> PE SC Received ChecWi/ Amount Permit/ Invoi-N Well IDN <br /> B Dale Service R uest M <br /> Codes In emitted <br /> � -tom rs'0 ,2( l ,uo.O� k o 00 <br /> wF:l.l.PUMP PERMIT <br /> EI ID<7aI�xR, <br />