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dOp <br /> WELLIPUMP PERMIT u �rvr eFkf- w— - <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKY A 95205 232(209)468-3420 &9 <br /> NON-REFUNDABLE PERMIT • www.sjgov.org/ohd 4XPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS G `CITYMP_ 64.. m <br /> c� D <br /> CROSS STREET APN__Q C/.(1y PARCEL SIZE 010 LAND USE APPLICATION# A <br /> c m <br /> OWNER f_nME/�) R"1�Fc^l �N"NJ[��G1�` (in <br /> / ,/ m <br /> OWNER. ! "QT'f`)►1�...1�t Z�1�Y_ N 47��`/'��111� "t "`�/��yy� �],�/� Cn'v/STATErzI, (/,n 1 TP[il !l)''r� <br /> CONTRACTOR �''nn �N!/,eL(/!/J(JL��►JZ.um .J.-i/(•( _ -P7H�yO�NEE(���,','/�+�{71( Vy7lD/ <br /> CONTRACTOR ADDRESS 0 1'Q01�tLN /C (/ CITYISTATEIZIP 1'J/U�I//L(l J q5D'YS <br /> SUBCONTRACTORICONSULTANT �T 1 PHONE <br /> SUBCONTRACTOR/CONSULTANT ADDRESS - ITY/STATEMP <br /> LICENSE k57 CG61 I D-09 Other NUMREW�(Z&1l(,0 EXPIRATION DATE <br /> BILLING PARTY: I OWNER CONTRACTOR SU13CONMCTORICONSULTANT <br /> DoMEsnc WELL SAMPLING:' General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE Domestic/PrivateInigation/Agricultural Industrial Water Quality Monitoring Soil Sampling/Characterization <br /> Public Water System �^elv r <br /> It different from Cramer. Water System Name Contact Name or Phone Number �rC �® <br /> TYPE OF WORK New Well Replacement Well Well Alteration/Modification Other 1/ <br /> Monitoring Well(s) #of wells Soil Boring(s) #of borings Geotechnical #of borings 3 <br /> Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair SAN J 202p <br /> New Pum Pum Replacement Pum Repair Raise Well CasinoQ(��N <br /> WELL CONSTRUCTION O M COVN <br /> Drilling Method Mud Rotary Air Rotary - Auger Cable Tool Push Point Other H�Lr O PAR I <br /> Proposed Well Depth ft Excavation in diameter ,Open Bottom Gravel Pack/Gravel Size in diameter MENr <br /> Conductor Casing in diameter / Conductor Casing Depth it <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Sched Steel Plastic 1 Stainless Steel Other <br /> Grout Seal Depth ft Neat Cement 194/b bag,5-10 gal water) Sand Cement sack mixn gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method ; Pumped Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By :;Driller i Pump Contractor j Other <br /> Concrete Pedestal .Dimensions:Width ft Length It Thick in Christy Box Stove Pipe <br /> PUMP Submersible urbine :Other HP:yv— Pump Set ft Standing Water Level h <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 /> �1 NCE NOTICE REQUIRED FOR <br /> /IjUSPECTIONS-PLEASE CALL(209)95 6 <br /> SIGNED 4 TITLE Lf DATE Z <br /> LJ <br /> // EPARTMENT USE,ONLY <br /> Application Accepted By �L✓L/p� Date 2130h.c.7 U Area Employee ID# ��✓IA <br /> Grout Inspection By f Date I SPECIAL Well Permit <br /> Pump Inspection By FY��i1La5t,.t. j(hLf,r„ Q. DateC1� 2 4 WAIVER Received <br /> Soil Baring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Amount Permit] Invoice# Well ID# <br /> Codes Into Cash Remitted ate Service Re uest# <br /> S C77*7 <br /> FH043-M OIIW019 WELL mUMP PERMIT <br />