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WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCK Tom CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT <br />CALL Z09 953-IbUir FOR INSPECTIONS InA11111t, 1 TEAR FROM UATE ISSUE <br />JOB ADDRESS <br />CITY21PTgafu _-Aq:�0-f-_ <br />CROSS STREET <br />OWNER NAME <br />APN,T �Q-�qQ PARCEL SIZE461 _LAND USE APPUCATION # <br />Pj/H��ONE -ou rq i I <br />OWNER ADDRESS <br />CONTRACTOR <br />I �xC WON <br />1^t( <br />PJZI <br />(' CITY/STATP�t\�/Tr ��- 1 <br />`' PHONE O ✓ t� <br />CONTRACTOR ADDRESS <br />CITY/STATEIZIP O +fI <br />SUBCONTRACTOR <br />PHONE <br />SUBCONTRACTOR ADDRESS <br />_ CrTY/STATEMP q <br />LICENSE )KC -57 0 C-61 <br />J D-09 <br />EXPIRAON DATE ' / <br />lj][� TI <br />❑ Other NUMBER !r[iJ <br />)OMESTIC WELL SAMPLING: 0 General mineraOL,OIROTRI t5aciena (93y I) U ulDrornucnlUr UP) Updnn iHJVZ) a ruscnn: ttioao/ <br />NTENDED USE 0 DomestWphvate XIrrigabonlAgricultural 0 Industrial C Water Quality Monitoring 0 Soil Sampling/Characterization <br />0 Public Water System <br />If Orflerem from Cwrw Water System Name Coolant Name or Phone Number <br />FYPE OF WORK WSW Well 0 Replacement Well 0 Well Alteration/MDdiflcabon 0 Other <br />0 Monitoring Wells) # of wells 0 Soil Boring(s) ""' ""' ti 0 Geotechnical <br />0 Out -Of -Service Well O Out -Of -Service Well Renewal O Cross -Connection Repair <br />n Me— a,rmn n P,,mn Rani—m—1 n Pumn Reoair 0 Raise Well Casino <br />Drilling Method aMud O Alr Rotary 0 Auger D Cable Tool ❑ Push Point ❑ Other <br />Proposed Well Depth fl Excavation I— in diameter ❑ Open Bottom 0 Gravel PackJGravel Size In diameter <br />0 Conductor Casing in diameter / Conductor Casing Depth It <br />Well Casing Diameter., In Thickness/Gauge/ASTM Schad JAD O Steel )Plastic 0 Stainless Steel 1 Other <br />Grout Seal D pth ft 0 Neat Cement (94 /b bag/S70 gel water) 2 and Cement _ sack mix/7 gal water <br />Bentonite (20% solids) 0 Other <br />Grout Placement Method umped 0 Free Fell D Other O Retardant / Accelerator (name) <br />PEDESTAL Installed By O Driller 0 Pump Contractor Cl Other <br />0 Concrete Pedestal ODlmenslons: Width ft Length It Thick in ❑ Christy Box L' Stove Pipe <br />PUMP O Submersible Turbine 0 Other HP Pump Set it Standing Water Level It <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 />M M 4�8 jH�Oy�U�/RRA NCE NOTICE REQUIRED FOR INS CTITS - PLEAf�,�7`��E CALL (209) 953-7 97 <br />SIGNED � Lo`�- TITLE �t r DATE .14 <br />DEPARTMENT USE ONLY <br />Application Accepted By - - Date 3 �. <br />Grout Inspection By Date <br />Pump Inspection By Date <br />Soil Boring Inspection By Date <br />COMMENTS i� t i7t'y�� -ff?ke?_�+ <br />Area S /- C. Employee ID# <br />❑ SPECIAL Well Permit <br />❑ WAIVER Received <br />Constructed Well Depth ft <br />PE SC Received Checldl Amount Permit/ <br />Codes Info B ,Cash Remitted Date Service Request i Invoice 0 Well ID# <br />EH04315 MUM <br />6-; -_# //7D6 '77�r <br />WELL (PUMP PERMrr <br />A <br />23 2020 <br />