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/'�-Ne-�""� ELL / PUMP PERMIT �Al SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPA ENr 304 E WEBER Av FL-STOCKY O NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTION'S EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS / 'w AD" CITY/ZIP v CROSS STREET APN ,ry ( PARCEL SIZE LAND USE APPLICATION# G a�^ OWNER NAME �/Yti/ v / I 0 t///V PHONE Zo [^ '�/�0�Y 0yyo� y OWNER ADDRESS �� ) � � L 20f CITY/STATE/ZIP �—OCk-^/-t'al`l ((f 1 ?.5-26_57 CONTRACTOR W O 0� A6 CAA S 161 P PHONE 57 s2' /Z� `[ 71S CONTRACTOR ADDRESS V sJ CITY/STATE/ZIP Z cr' !73--t 7 SUBCONTRACTOR L C-&A / / �^� �` PHONE 9,(y'7, p6'7A // SUBCONTRACTOR ADDRESS C! �S� L D!�[j J CITY/STATE/ZIP Tf LICENSE ❑C-57 ❑C-61 ❑D-09 0140,ther NUMBER EXPIRATION DATE GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section O� INTENDED USE ❑Domestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization ❑Public Water System If different from Owner: Water System Name /Contact Name or Phone Number TYPE OF WORK ❑New Well ❑Rep ement Well ❑Well Alteration/Modification them onitoring Well(s)`- -#of wells ❑Soil Boring(s) #of bo,_ ❑Geotechnical of borings ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair j ❑New Pump ❑Pump Replacement ❑Pump Repair c� WELL CONSTRUCTION Drilling Method 13Mud�RRotary ❑Air Rotary 4ttger ❑Cable Tool ❑Push Point ❑Other Proposed Well Tool ❑Push Point ❑Other42�2—ft Excavation in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter ❑Cot or Casing in diameter / Conductor Casing Depth ft Well Casing Dia er-6 to Thickness/Gauge/ASTM Sched ❑Steel ❑Plastic ❑Stainless Steel ❑Other Grout Seal Depth ft ❑Neat Cement(94 lb bag/S-10 gal water) ❑Sand Cement sack mix/7 gal water )25 t ite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted Grout Placement Method ❑Pumped )!(Eme Fall ❑Other ❑Retardant/Accelerator(name) PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑ Other ❑Concrete Pedestal Dimensions:Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe PUMP ❑Submersible ❑Turbine ❑Other HP Pump Set ft Standing Water Level ft I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. �1 MI UM 24 HOUR ADVANCE NOTICE EQUIRED FOR INSPECTIONS SIGNE_ --��_/_,I�,e/1 � TITLE 5z6aT DATE Ile- S N Os ENVIFONME T L DE:)AF TM N DEPXR MENT USE ONLY / Application Ac ted t ! Date Area Employee ID#QL"-Z Grout Inspection By ate Z:3C.// O(,_, ❑ SPECIAL Well Permit Pump Inspection By Date ❑ WAIVER Received Constructed Well Dep ti It / COMMENTS ^��'� �'"T/�/icy-1 //'7 zY��i// /7i PE SC Receivedheck#/ Amount Date Permit/ Invoice# Well ID# Codes Info By Cash Remitted Service Re uest# ERD 43-02-006 WELL PUMP PERMIT 1/27/2005