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UAV/ELUPUMP PEERPM <br /> `JAN JOAQUIN COUNTY ENVIRONMENTAL NEALTI-1 DEPT '1868 East Hazelton Avenue-STOCITON CA 95205-62.32 - (209)468-3420 <br /> N01 ill-REFUNDABLE PERMIT CALL 209 953-7097 FOR 114SPECTIONS EXPRES 'I YEAR FROM DAT E ISSUED <br /> rn <br /> z S j CITY/ZIP &(1�i/A `f R��(� C'1q��� M <br /> .10[3 ADDRESS _ -r }o <br /> rfl / v €',ARCEL SIZE LAND USE APPLICATION�# <br /> CROSS STREET t-1P <br /> N <br /> OWNERtIAMC / 0/ Pq Pt-IONCaV/ V'-' <br /> J57JI? A1W f/STATE/ZIP ez C^ <br /> OILINER:'.DDRESS el <br /> CONTRACTOR / z 41 0- W PHONE6 <br /> CONTRACTOR ADDRESS a( �� ��fi �� �� CITY/STATEIZIP / /C A C"/ ] ` 'K <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE -57 ❑ C-61 ❑ D-09 ❑ Other NUMBERqR5 EXPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y (Township Range Section <br /> INTENDED USE '_Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑Water Quality Monitoring 11 Soil Sampling/Characterization <br /> (❑ Public Water System <br /> If different from Owncr: Water System Name Contact Name or Phone Number <br /> a YPE Or WORK ❑ New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other <br /> ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings ❑ Geotechnical #of borings <br /> 0 Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> New PUMP ❑ Purnp Replacement ❑ Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUC ION <br /> Drilling Method ❑ Mud Rotan,/ ❑ Air Rotary ❑Auger ❑ Cable Tool ❑ Push Point ❑ Other <br /> Proposed Well Depth it Excavation in diameter- ❑ Open Bottom ❑ Gravel PacldGravel Size in diameter <br /> ❑ Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_ in Thickness/Gauge/ASTM Sched ❑ Steel ❑ Plastic ❑ Stainless Steel ❑ Other <br /> Grout Seal Depth ft ❑ Neat Cement(94/b bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water <br /> ❑ Bentonite(20%solids) ❑ Other <br /> Grout Placement Method ❑ Pumped ❑ Free Pall ❑ Other ❑ Retardant/Accelerator(name) <br /> PEDEST.AI_ Installed By ❑ Driller ❑ Pump Contractor ❑ Other <br /> ❑ Concrete Pedestal Dimensions:Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe <br /> PUMP Submersible❑ Turbine ❑ OtherHP L Pump Sef d ft 'Standing Water Level 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. qts <br /> MI UNIHOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> SIGNED/ tS^r TITLE C10i01 DATE <br /> N i <br /> 1+1 1 1 1 <br /> D P RTMENT US 416 <br /> LY <br /> Application Accepted By Date Area Employee ID# <br /> Grout Inspection By Date SPECIAL Well Peffgi it <br /> Pump Inspection By AA_ Date WAIVER ReCelVord <br /> Soil Boling Inspection By Date Constructed Well Depth <br /> COMMENTS <br /> PC SC ReceivedAmount Date Permit/ Invoice 6 Well ID# <br /> Codes Info By Z a3Ga Remitted Service Re uest# <br /> CHD 43.06 WELL/PUMP PERMIT <br /> 3/04/08 <br /> e <br />