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JOB ADDRESS <br />CROSS STREET <br />OWNER NAME <br />NON-REFUNDABLE PERMIT CALL M:19) 953-7697 FOR INSPECTIONS <br />CONTRACTOR OOMMS Id4 • <br />CONTRACTOR ADDRESSCRO D 10i J( <br /> it114 <br />OWNER ADDRESS . A <br />s-z-[p, nova 7M]- <br />APN .15'1 - z(e0 - PARCEL SIZE <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 EAST MAIN STREET - SrocicroN CA 95202 - (209) 468-3420 <br />EXPIRES 1 YEAR FROM DATE ISSUED <br />CITY/STATE/ZIP <br />pHoNE?CeM 7-a 1q69 <br /> <br />95a3t1, <br /> <br />ptpaNg 93/ ,5„wn <br />oTyisTAItizA 60-n(419 -,,s—> <br />CrrdZip q5aM <br />LAND USE APPLICATION # <br />TATE/ZIP <br />L C-61 0 D-09 0 Other NUMBER <br /> Township Range Section <br />EXPIRAT)ON DATE /-S11.1 <br />SUBCONTRACTOR <br /> PHONE <br />INTENDED USE <br />TYPE OF WORK <br />11 Monitoring Well(s) <br />.0 Out-Of-Service <br />New Pum Pum <br />WELL CONSTRUCTION <br />(Domestic/Private Li Irrigation/Agricultural 0 Industrial El Water Quality Monitoring <br />ublic Water System <br />If different from Owner: <br />E Soil Sampling/Characterization <br />Contact Name Of Phone Number Water System Name <br />El New Well 0 Replacement Well C• Well Alteration/Modification C Other <br /># <br /> # of wells 0 Soil BBoring(s) <br />of bortngs of harings Geotechnical <br />(7 Out-Of-Service Well Renewal 0 Cross-Connection Repair <br />Replacement ri Pump Repair 0 Raise Well Casing <br />DrillIng Method 0 Mud Rotary 0 Air Rotary 7 Auger El Cable Tool Li Push Point 0 Other <br />Proposed Well Depth <br /> ft Excavation in diameter 1.1 Open Bottom u Gravel Pack/Gravel Size in diameter <br />Conductor Casing in diameter / Conductor Casing Depth <br /> ft <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched 1_2. Steel u Plastic 0 Stainless Steel 0 Other <br />Grout Seal Depth ft El Neat Cement (94 lb bag/5-10 gal water) <br /> D Sand Cement sack mtxfi gal water <br />Bentonite (20% solids) C Other <br />Grout Placement Method 0 Pumped Ti Free Fall U Other 0 Retardant / Accelerator (name) <br />PEDESTAL Installed By 0 Driller U Pump Contractor Other <br />0 Concrete Pedestal Dimensions: Width ft Length ft Thick In o Christy Box 0 Stove Pipe <br />PUMP kubmersibleri Turbine 0 Other HP Pump Set ft Standing Water Level &A . ft <br />I HEREBY CERT FY THAT l 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 COMPUANCE WITH ALL <br />wORKE COMPENSATION <br />411110 <br />4 H' URADVANCE NOTIC R QUIRE FOR INSPECTIONS <br />SIGNE MP 4/ a /le TITL 4 DATE 1.1-71)7 <br />IP <br /> <br />PAYMENT <br /> RECE V:1) <br />APR 2 2 ON <br />Joni !EN COLIINTrY <br />EN VIP 9N ,A .E ITlL <br />elEAL 11 • <br />.• <br />Application Accepted By Date 'IC Area Employee ID# 5 3 <br />az DEPARTMENT U E ONLY <br />Area <br />Grout lnspe Date II SPECIAL Well Permit <br />Pump inspe Date -,C7,` El WAIVER Received <br />Soil Boring Inspection By <br /> Date Constructed Well Depth ft <br />COMMENTS <br />PE <br />Codes <br />SC <br />Info By <br />ReceivedCtQest____) ctti Amount <br />Remitted Date i I. <br />Permit/ <br />Service Request # Invoice # Well ID# <br />*3 er oso xi-C.,--- \\ b tA lc, V6---t1 v-0 71.1/6 , sgoo 51103 (,..poo 31 kel <br />'ZHO 43-06 WELL iPUMP PERMIT <br />6/04/06