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El-ID 43-06 <br />4/30/12 <br />WELL /PUMP PERMIT <br />Area g/(-6 Employee ID <br />DEPARTMENT USE/ ONLY <br /> Date q <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STocrcroN CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT CALL (209) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS i /09,11 -2 5- T irle, 44 e Crraie <br />CROSS STREET cm/4y t2D4pN DD I 7 <br />be3c, <br />CITY/STATE/ZIP <br />OC.J 11(11:Cf ( pHoNE,209 S( Lf9 <br />CONTRACTOR ADDRESS 1 (0 _ST--." C/110 et: ? c)/- CRY/STATE/ZIP 'f(-4 )-1-/I. <br />SUBCONTRACTOR PHONE <br />OWNER NAME <br />OWNER ADDRESS <br />CONTRACTOR <br />0 <br />PARCEL SIZE ' LAND USE APPLICATION # <br />SUBCONTRACTOR ADDRESS <br />GEOGRAPHICAL INFORMATION: Coordinates X <br />CRY/STATE/ZIP <br /> <br />EXPIRATION DATE <br /> Township Range Section <br />LICENSE 0-57 1-C-61 0-09 ' Other NUMBER #)241 /(.0 <br />p.0.0.0‘? <br />Water System Name <br />/New Pump Pump Replacement <br />Auger <br />WELL CONSTRUCTION <br />Drilling Method Mud Rotary ' Air Rotary Cable Tool • Push Point Other <br />Grout Placement Method Pumped Free Fall Other Retardant / Accelerator (name) <br />TYPE OF WORK Klew Well Replacement Well <br />Monitoring Well(s) # of wells <br />Out-Of-Service Well <br />Well Alteration/Modification Other <br />Sot borings <br />Soil Boring(s) Geotechnical <br />Out-Of-Service Well Renewal Cross-Connection Repair <br />Pump Repair Raise Well Casing <br /># of borings <br />L,ontact Name or Phone Number <br />Proposed Well Depth ft <br />Well Casing <br />Grout Seal sack mix/7 gal water <br />, • Gravel Pack/Gravel Size <br />ft <br />Plastic • Stainless Steel Other <br />Sand Cement <br />Excavation in diameter • Open Bottom <br />Conductor Casing in diameter / Conductor Casing Depth <br />Diameter in Thickness/Gauge/ASTM Sched Steel <br />Depth ft • Neat Cement (94 lb bag/5-10 gal water) <br />Bentonite (20% solids) • Other <br />in diameter <br />INTENDED USE -1c/Bomestic/Private Irrigation/Agricultural <br />Public Water System <br />If different from Owner. <br />Industrial Water Quality Monitoring Soil Sampling/Characterization <br />ft Thick in Christy Box -, Stove Pipe <br />PEDESTAL Installed By Driller Pump Contractor " Other <br />Concrete Pedestal -Dimensions: Width ft Length <br />HP 3 X.Submersible Turbine Other ft Standing Water Level rC) ft PUMP Pump Set fu <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 W H THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENA LAWS. <br />OT E REQUIRED FOR INSPECTIONS - PLEASE CALL (209)39 3- 697 <br />TITLE (Nei/ie DATE 91 / SIGiED./ <br />it A <br />yo# I. <br />A/ <br />OU ADV <br />Application Accepted By <br /> <br />Grout Inspection By Date 0 SPECIAL Well Permit <br /> <br />Pump Inspection By Date tA 0 WAivER Received <br /> <br />Soil Boring Inspection By Constructed Well Depth ft <br />COMMENTS j.,4 pc!poi t Po340 <br />PE <br />Codes <br />SC <br />Info <br />Received <br />B <br />heckiti <br />-- as <br />Amount <br />Remitted Date Permit/ <br />Service Request # Invoice # Well ID# , <br /> /2_171-2 -- lt,/•S -dL Iriiii) <br />r t OUt°00i- I .-t4-0-‘ <br />Date :SSMIOCIV 311S