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WELL / PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 301 E WEBER Avit 3" FL - STocKToN CA 95202 - (209)16&3120 <br />NUN -REFUNDABLE PERMIT (:%1,1.(209)953-7697 I-1 IH I \NPF:CI IONS EXPIRES I YEAR FROM DATE ISSUEE <br />'JOB ADDRESS7�Q((.).J Kd CITY <br />% <br />CROM STREET � _y ,r � / • APN Z1't-c 0 -Z O PARCEL SILL O' (O LA.ND USE ArrLI/CATIII00% #`/�//_ <br />OWNER NAMI Qd^Y kze-U Qd <br />OWNER ADDRESS (6 lya `.5,ra(o.-� o-o4i, Rd Crry/STATLMP <br />CONTRAP►DN/R���__)— C <br />CoNTRAcroRADDRESS(2i 7LCrryWATvwICA - ",X6 <br />SUBCONTRACTOR PHONE <br />SUBCONTRACTOR ADDR[SS Crrv/SrATE/IJP <br />LlcnI <br />vsm ❑ C•57 OIC -61 ❑ D-09 ❑ Other NUMREO�O E7[rtisATION DATE a�6 <br />GEoGkApwAL INFORMATrom Ceor'dbRas X Y TRwB.iL Rase N..*" <br />MINDED USE ,W—mesbc/Privstc ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Qulity Monitoring ❑ Sal Sampling/Characterization <br />❑ Public Water System <br />TYrt OF WORK ❑ New well ❑ Replacement Well ❑ Well Aherstiaa/ModiLcation ❑ Other <br />❑ Monitoring Well(s) # of wells O Soil Boring(s) ❑ GCOteclalit8l _a "r bare <br />❑ Out-Ofservice wqt ❑ out -of -service Well Renewal ❑ CrmrCaaoection Repair <br />DrRYDE Med and ❑ Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other__ <br />Propmed Well Depth_ R Excavation in diameter ❑ Open Bottom ❑ Gmvcl Pack / Gravel Size in diameter <br />❑ Conductor Casing _ in diameter / Condnwtor Casing Depth ft <br />Well C.A g Diarneter _&_in ThirJrness/Gauge/ASTM Sched ❑ Steel ❑ Plastic ❑ Stainless Steel ❑ Other _ <br />Groat Sea] Depth R ❑ Nest Cement (9I /b bag / 5-10 got artier) ❑ Sand Cement _ _ _ .rack ari.v 17 gal water <br />❑ Bentonite (20% solids) ❑ Manu&ctwer Spec % solids % Name ❑ <br />Specson Fik ❑Specs Submitted <br />Gr"t Pfeceseat Mctb0d ❑ Pumped ❑ Frce Fall ❑ Other ❑ Retardant / Accelerator (Banc) <br />Insta ed By ❑ Driller ❑ Pump Contractor ❑ Other _ _ -- - - -- <br />❑ Concrete Pedestal Dbuesslons: Width il Length R Thick in ❑ CbrYly Bu ❑ SdYe Pipe <br />I Submersible ❑ Turbine ❑ Other HP / .2 Pump Set / r ft cea,.t�..g a/.r.r r..,.r n <br />t <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. 1 ALSO CERTUY THAT MY REQUIRED LICENSE IS <br />CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM M COMPLIANCE WITH ALL <br />WORKERS COMPENSATION LAWS. <br />//�1//��/ ,MINIMUM 24 IIOI R ADVANCE NOFI( E K (lyl['I K'E/^D FOR INSPF:CTIO\ti }/yrr}��� <br />$IC,\t:D .I Com--' TITLE /r>I•UY(/if DATE(/) <br />T _ <br />Application Accepted By <br />Grout Inspection By <br />Pump Insp—on By <br />Cootrected Well Depth <br />COMMENTS <br />DEPARTMENT <br />ySE/ONLY <br />Date j=mss <br />R <br />It <br />AYMENT <br />ECEIVED <br />UG 2 5 2005 <br />JOAQUIN COUNTY <br />NVIRONMENTAL <br />,ITH DEPARTMENT <br />Ara Employee IDV# <br />❑ SPECIAL Well Permit <br />❑ WArmRetelved <br />F3m 4342-006 <br />1/27n M5 WELL PIMP PE"IT <br />