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PARCEL SIZE/ 3g LAND USE APPLICATION if <br />crryizip <br /> <br />r:f 9 <br />PHONE ito3 — 13 <br />CITY/STATE/ZIP C ci 3 7 <br />PHONE <br />CITY/STATE/ZIP flIp/ C 9,2/./s• <br />PHONE <br />ciTyisTATEmp tta-rs ft) cis-74 ,7 :SS38C1C11/ 311S JOB ADDRESS / <br />CROSS STREET [ft" OA 0 t"..) y APN 51 '7 <br />OWNER NAME /4,,,,1,4,,J d <br />fo.go>c 6 <br />tJc.ft <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOck-rON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT CALL (209) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />OWNER ADDRESS <br />CONTRACTOR <br />CONTRACTOR ADDRESS .c..7 ,••0 tAj :1 <br />SUBCONTRACTOR 110 <br />SUBCONTRACTOR ADDRESS I k rY A (be,- s <br />LICENSE 5 C-57 ' C-61 1 D-09 (1 Other NUMBER ft EXPIRATION DATE 31- <br />GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br />INTENDED USE # Domestic/Private Irrigation/Agricultural [1 Industrial LI, Water Quality Monitoring LI Soil Sampling/Characterization <br />I I Public Water System <br />If different from Owner: Water System Name Contact-tame or Phone Number <br />TYPE OF WORK 111 New Well I I Replacement Well <br />LI Monitoring Well(s) it of wells <br />*Out-Of-Service Well U Out-Of-Service Well Renewal <br />H New Pump r - Pump Replacement D Pump Repair <br />Geotechnical <br />LI Cross-Connection Repair <br />U Raise Well Casing <br /># of borings <br />CI Well Alteration/Modification rI Other <br /># CI Soil Boring(s) of borings <br />WELL CONSTRUCTION <br />Drilling Method 4 Mud Rotary u Air Rotary ii Auger L] Cable Tool L1 Push Point FL Other <br />Proposed Well Depth_"- ) ft Excavation in diameter :t Open Bottom )91 Gravel Pack/Gravel Size <br /> f/y in diameter <br />Well Casing <br />Grout Seal <br />LI Conductor Casing in diameter / Conductor Casing Depth <br />Diameter ‘,) in Thickness/Gauge/ASTM Sched Steel <br />Depth c; c=4:) ft H Neat Cement (94 lb bag/5-10 gal water) <br />Bentonite (20% solids) [I Other <br />ft <br />A_Plastic 12: Stainless Steel LI Other <br />LI Sand Cement sack mix/7 gal water <br />Grout Placement Method Pumped H Free Fall Other H Retardant / Accelerator (name) <br />PEDESTAL Installed By '1 Driller H Pump Contractor Other <br />Concrete Pedestal Dimensions: Width ft Length <br />PUMP pef7*-S16mersible Turbine I Other <br />ft Thick in r Christy Box IT Stove Pipe <br />HP Pump Set ft Standing Water Level _4-0 T ft <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 />MINIMM HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />SIGNED <br /> <br />TITLE - 41C "C DATE 7•' /F <br />t-T-12 <br />I5,1 <br />ftArz,. <br />1/.JL. I f'* <br />2015. Js <br />'1'441/4":10, 411V CDU,v7 <br />-"v7- ‹/V7 <br />DEPARTMENT USE ONLY <br />Date -7/ <br />Date C.,?_ LI SPECIAL Well Permit <br />Date L WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth ft <br />COMMENTS <br /> <br />\c"•-• <br /> \f‘c..""0 • kiN <br />L) <br /> v•-)`‘:: ‘C- 1, 7 to 0 <br />PE <br />Codes <br />SC <br />Info <br />Received <br />B <br />Check Amount <br />Remitted Date Permit/ <br />Service Request if Invoice if Well ID# 14.., <br />1 . IL 1 bl /S77 a : 1 -4 -+ i, i A". , 1 s3 77 12 2- 1-Aa-k II7 6•)1-) <br />i ( /Y-- /.5-5-77 IL/ <br />4,-yrz 7,#) <br /> <br />1-Ap--1‘4 opc\-3-47 \ WELL /PUMP PERMIT <br />Application Accepted By <br />Grout Inspection By <br />Pump Inspection By <br />Area c7/4 7/ Employee ID#P44