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WELL/PUMP PERMIT <br /> SON JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3"°FL-STOCKI'ON CA 95202 -(209)468-3420 <br /> NON-REFUNDABLE PERMIT /CAALL 2(039 I <br /> 953-7697 FOR INSPIX�" IO"S EXPIRES YEAR FROM DATE ISSUED <br /> JOBADIRESS <S1 AY/na U�_/ CRY/ZIP (-Llr1tr'`Xf R <br /> CROSS STREET �.�t/"/J /`'" API 'D('-7- D <br /> PARCEL SIZE 1,J\AND USE <br /> �e/ y►�1 ,�,.t�'�,�'1 ~�d~ A�PP�LICAyTIJO�N <br /> OWNER NAME PHONE?/6 <br /> OWNER ADDRESS / CITY/STATE/ZIP "l,7 t-4- <br /> / <br /> 11yQ <br /> • <br /> s7+ •LCONTRACTOR A --A nyv� PHONE 3y <br /> CONTRACTOR ADDRESS � <br /> s- <br /> CITY/STATFIZIP 1/W�/�/'�/✓�L^ <br /> SUBCONTRACTOR PHONE_ <br /> SUBCONTRACTOR ADDRESS CITY/STATF%ZIP <br /> LICENSE XC-57 ❑C-61 ❑D-09 ❑Other NL'MBEI3_? 3'9S EXPIRATION DATE -0 / <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section_ <br /> INTENDED USE Domestic/Private ❑Imgation/Agriculturai ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization <br /> ❑Public Water System _ __ <br /> Irditferentf—Owner. .", ysmm,ame onuct ame or Phre N..k, <br /> TYPE OF WOR New Well ❑Replacement Well ❑Well Alteration/Modification ❑Other <br /> ❑Monitoring Well(s) #of wells ❑Soil Boring(s) "6rbor p ❑Geotechnical s arborinri <br /> ❑010-0f-Service Well ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> ACNew Pump ❑Pump Replacement ❑Pump Repair <br /> WELL CONSTRUCTION <br /> Drilling Method>6-Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Other A\ <br /> 1 /V <br /> Proposed Well Depth'- ft Ezcavation�in diameter ❑Open Bottom Gravel Pack/Gravel Size in diameter <br /> ❑Conducto?asing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter s in Thickness/GaugeJASTM Sched Z.JD ❑Steel ArPlastic ❑Stainless Steel ❑Other <br /> �i�t l� <br /> Grout Seal Depth�(_7 ft ❑Neat Cement(94!h hug 15-10 ga/water) Sand Ccmlent 1013 sack mir/7 gal water � <br /> ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted <br /> Grout Placement Method--'V Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By , %*briiier ❑Pump Contracto ❑ Other <br /> ❑Concrete Pedestal Dimensions:Width fl Length R Thick in ❑Christy Bos ❑Stove Pipe <br /> PUMP _-_T!'�SUbmersible ❑Turbine ❑Other lip Pump Set It Standing Water Level It r <br /> 1 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 C <br /> WORKERS COMPENSATION LAWS. <br /> A�-IINIINU�I 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS r <br /> SIGNED �' TITLE DATE � <br /> Cr - <br /> C.. <br /> p <br /> /! ? <br /> ef <br /> ! / <br /> 2 ) - <br /> zi <br /> / F - <br /> 3 - <br /> \14PN H <br /> DEPARTMENTU E ONLY <br /> Application Accepted By - "`"_ Date /( 1 Area Employee ID# �S 4 Ct c/-C, <br /> Grout Inspection B ate �`--�f' ❑ SPECIAL Well Permit <br /> Pump Inspection B .t _ Date��/J�/�'�� ❑ WAIVER Received <br /> Constructed Well Depth A <br /> COMMENTS C-cr) L ur c;F hf C c,',-1 t1; �iy�L, Lr[,f'�3'-•.) / ,^i/OXL Cr L,!I/4�C=- !�L-trJ�CGY: / �9�".iJc:I <br /> �-e c- .'e -ZC. <br /> PE SC Received LLChccldliki Amount Dae Permit/ IDvoice# Well IDN <br /> Codes Info - Cash emitted Service Request# <br /> -i 3 4,c rSv °7- 3> L !i p S (4Ch:,3 ! ;tlFtrt c/ <br /> 4ST) Cw T5•.-u" G.5 0y Y 4)(-32 <br /> EHD 43-0:-006 c Sc./'-1,r,/i<-. I-.r-Z. f� C></ILCZ.-/IL-C:LC/fD rcrC �Cla_. M'ELI,�VANPE7LNIT <br /> 1'27/2005 / <br />