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ll <br /> 1' 1 ) ETD <br /> LYVELL/PUMP PERulYu011 <br /> `..i^'AN JOAQUIN COUiq-n LNVI MENTAL 1-IEALTI-I DEPT '1868 East Hazelton Avenue-STOCK-1 ON CA 95205-6232 - (209)468-3420 <br /> NON-RIEFUNDA' E P CALL 209 953-76697 FOR INSPECTIONS EXPIRES I YEAR FROM DAT E ISSUED <br /> QS3i O M <br /> ..106 r-%DDRE4' a <br /> Crn•IZIP Tr«� <br /> ^ "� . 0 <br /> CROSS S T REET \--�'Ti�S�+ LiJ�_' O I�ARCEL SIZELAND USE APPLICA T ION# m <br /> OWNER IIAfl9E LSV QI)—)AtC0 ��� TA L- c�llorJ� hS 0) -b 0' _ c <br /> OVVNE-R. ��� • i.�d ��Q CITYISTATE/ZIP t 4r-4 <br /> s l rt n - �,,E 2— ty <br /> LB <br /> CONTRACTOR ,oy� _' <br /> CONTRACTOR ADDRESSAA% CITY/STATE/ZIP /I IQGIF <br /> SUBCONTRACTOR PI-l0i'!E <br /> SUBCONTRACTOR ADDRESS CITY/STATEIZIP <br /> LICENSE >1 �C-57 ❑ C-611 ❑ D-09 ❑ Other NUMBER EXPIRATION DAT G azwl <br /> GEOGRAPHICAL INroRM,`-\TION: Coordina-ies X Y TOwnsh110 Range Section <br /> INTENDED 1-ISE Ix 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 OF WORK )(New Well eplacement Well ❑ Wull Alteration/Modification ❑ Other <br /> ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) ft of borings ❑ Geotechnical It of borings <br /> ❑ Out-Of-Service Well ❑ Out-Of-Sctvice Well Renewal ❑ Cross-Connection Repair <br /> ❑ New Pump ❑ PUrnp Replacement ❑ Pump Repair ❑ Raise Well Casing <br /> "IIELL CONS T RU 'ION <br /> Drilling iVletiiod 6XIMud Rotary, ❑ Air Rotary ❑ Auger ❑ Cible Tool ❑ Push Point ❑ Other <br /> Proposed Well Depth�d ft Excavation 11 r in diameter ❑ Open Bottom xGravel PacldGravel Size in diameter <br /> ❑ CondUC'i01'Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter-'k in Thickness/Gauge/ASTM Sched , ❑ SteelPlastic ❑ Stainless Steel ❑ Other <br /> Grout Seal Depth l6 a ft ❑ Neat Cement(94 Ib bag/5-10 gal water) ❑ Sand Cement sack mix17 gal water <br /> Xentonitc(20%solids) ❑ Other <br /> Grou;:Placement Method Pumped ❑ Free Pall ❑ Other ❑ Retardant/Accelerator(name) <br /> PEDEST,gI_ Installed By ❑ Drillerump Contractor ❑ Other <br /> ❑ Concrete Pedestal Dim rasions:Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe <br /> huMP ❑ Submersible❑ Turbine ❑ Oilier I-IP Purnp Set ft `Standing Water Level ft <br /> I HEREDY CERTIFY TI-11-1T 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 THAI.1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSAT ION LAWS. <br /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> SIGNED TITLE—�/ � DAIc <br /> u <br /> OOF-- <br /> — -- o X19 <br /> 01 <br /> O N�. <br /> -- — -- --- — — NT <br /> -- OF — — — ----- — — — — — — <br /> PA ,TM ENT U E N L Y <br /> Application Accepted By Date Area v/ "G Employee ID-1 <br /> Grout Inspection By Date SPECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth n <br /> COMMENTS <br /> PE SC Received Che� Amount Permit/ ZJy�' <br /> Invoice 1 Well BDst <br /> Modes I1"o ByCash Remitted Date Service Request <br /> �0- <br /> 3717 ?/� 2 'c°I WP 3°I(S <br /> -2l c°I l�Q o 2 <br /> EFID 43-06 WELL/PUMP PERMIT <br /> 3/04103 <br />