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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL H, DEPT 1868 East Hazelton Avenue fON CA 95205.623/ATE <br /> )46&3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROMSSUED <br /> JOB ADDRESS A,Ttj , CASI I ITH S�QE F-T Cm21P Il 1� D <br /> CROSS STREET E \�1 S�T�E C � APN Z-5S O L c 2 0 <br /> �/ p A U -V S PARCELS blyt)O iL{AND USE APPLICAn i# z <br /> OWNER NAME I fLf\ r GFFI(c t uA tA, LIQC PHONE I) Z <br /> OWNER ADDRESS 3 Z(-I CA-sr-ill./t1' 5`wccr -` CrfY/sTATmw A <br /> CONTRACTOR IPtatJ(-,E A rtdj Q(,/jMrti1 rA` LinJi GES I N l- PHONE;{.)(C%Ni �),�j� .}�0l/ <br /> CONTRACTOR ADDRES(S^ ��n�U r iV 7'IN LLnI f� :�_ 5-rC, ZCX� CITVISTATE/LP /�J� L AIV -{�h7 6 1(�� <br /> SUBCONTRACTOR V tl�CJ 1�7�7TrLN r�lIE.I l ciz-s , y`,PH�IONE�S),A -•T b - 011 <br /> SUBCONTRACTOR ADDRESS L-J(L 19-1 7 A L-D � W KI CrfY///STATEMPT� 1� CAH 9'L yS <br /> LICENSE -57 1 C-61 O D-09 O Other NUMBER ��41i L EXPIRATION DATE 0 j �� <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section <br /> INTENDED USE 7 Domestic/Private J Irrigation/Agricultural -1 Industrial Water Quality Monitoring JgSoil Sampling/Characterization ✓Nk<,( <br /> n Public Water System <br /> If different from Owner Water System Nam C nta ame or one um r <br /> TYPE OF WORK 7 New Well I Replacement Well C Well Afteration/ModificatiI Other <br /> ; <br /> Monitoring Well(s) #of wells ><Soil Boring(s) C11 a of bonngs Geotechnical 9 of borings <br /> Out-Of-Service Well Out-Of-Service Well Renewal E Cross-Connection Repair <br /> New Pump 11 Pump Replacemen a Pump Repair :Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method I Mud Rotary E Air Rotary E Auger Il Cable Tool/ E Push Point 1.i Other <br /> Proposed Well Depth ft Excavation in diameter Open Bottom 11 Gravel Pack/Gravel Size in diameter <br /> i Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Sched' j Steel E Plastic E Stainless Steel i5 Other <br /> Grout Seal Depth It E Neat Cement(94 Id bag/5-10 gal water) E Sand Cement sack mix/7 gal water <br /> Bentonite(20%solids) E Other <br /> Grout Placement Method !i Pumped ❑Free Fall 7 Other I Retardant/Accelerator(name) <br /> PEDESTAL Installed By 1 Driller E Pump CoPtractor ❑ Other <br /> i Concrete Pedestal Dimensions:Width ft Length ft Thick in E Christy Box E Stove Pipe <br /> PUMP Submersibles i Turbine i i Other HP Pump Set It Standing Water Level ft <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 /> 99jj�ljj}}��ADVANCE NOTICE REWIRED FOR I�ECTIONS <br /> SIGNED_ TITLE DATE / <br /> ENT <br /> RE AVE® <br /> 219!:v <br /> S J D kC UI N COUNTY <br /> VIR ENTAL <br /> E LT T rJ ARTMENT <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date Area Employee ID# <br /> Grout Inspection By Date SPECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth It <br /> COMMENTS <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Well IDN <br /> Codes Info B Cash Remitted Service Re uest# <br /> b5" 313 l,6 �SDo �'�► 3 6D(o7 <br /> 0 <br /> EHO 4306 WELL/PUMP PERMIT <br /> 8/04/08 <br />