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0 WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENT„_. .EALTH DEPARTMENT 304E WEBER ASTOCKTON CA 95202-(209)465-3420 <br /> NON-REFUNDABLE PERMIT CA.IA, 209 953-7697 l,OR.INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED <br /> `/�� �fj t3y <br /> JOB ADDRESS S S• !/f I /�JQ/') /d CITY/ZIP 14911 y <br /> CROSS STREET /�� APN 1 3 I �V /`�^I V PARCEL SIZE LAND USE APPLICATION##•r/��i Q/v�� C%1 <br /> OWNERNAME G e- PHONE <br /> /t�V/rq- /t0 /- ' / / <br /> OWNERADURESS I Q/A 1 1 1` G 11 A 0l CITY/STATE/ZIP �{a 4[i{�2CA '35.J3LYL <br /> CONTRACTOR C/LJ' • I J I Iv //�� c �j ] {PHONE V,��f✓ -a/ /1- !1 / / <br /> �N.� f�( uGItz4 VY (JVI1G I�.J CITY/STATE/ZIP j% /S4,n OC1�� C� 1�(N <br /> CONTRACTOR ADDRESS p I �-��-1+�-/�-�jG��{i �f�'] <br /> SUBCONTRACTOR 4 UC c � V P IG Y +i Gn [�,PPHHONE(X O - /!r,1,� �j'r�]7 o <br /> SUBCONTRACTOR ADDRESS� ' W/A U/� CITY/STATE/ZIIPP„JJ G C..q-30-67 <br /> �,J %�ty�y <br /> LICENSE -57 ❑C-61 ❑D-09 ❑Other NUMBER I���0 EXPIRATION DATE "/ 3G-G/ <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township�N Range Section_ <br /> INTENDED USE ❑Domestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring X, <br /> oil Sampling/Characterization <br /> ❑Public Water System <br /> If different from Owner: water System Name Contact Name or P one um r <br /> TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification ❑Other <br /> —L 1 n #of borings 11 Geotechnical #ofborings <br /> 11 Monitoring Wells) #of wells �1Soil Boring(s) <br /> ❑Out-Of-Service Well ❑Out-Of-Ser.Wce Well Renewal ❑Cross-Connection Repair <br /> ❑New Pump ❑Pump Replacement ❑Pump Repair <br /> WELL CONSTRUCTION <br /> Drilling Method ❑Mud Rota ❑Air Rotary *uer ❑Cable Tool ❑Push Point ❑Other <br /> Proposed Well Depth_ft Excavation t_in diameter ❑Open Bottom ❑Gravel Pack/Gravel 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(941b bag 15.10 gal water) ❑Sand Cement sack mix/7 gal water <br /> ❑Bentonite(20%solids) ❑Manufacturer Spec%solids_% Name 11Specs on File ❑Specs Submitted <br /> . <br /> Grout Placement Method ❑Pumped ree Fall ❑Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑ Other <br /> ❑Concrete Pedestal Dimensions:Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe <br /> PUMP ❑Submersible ❑Turbine ❑Other HP Pump Set 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. <br /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> S ✓ G TITLE IGNEDJs/tT� v✓ DATE <br /> a �ZG1 I fT O� <br /> 1 <br /> ————————————————ig <br /> ------------- <br /> t F- <br /> EP RTMENT USE ONLY <br /> Application Accepted By_ _ Date Dec 13, 204>5 Area Employee ID# <br /> ��l��l ��I��/ <br /> Grout Inspection By Date 13SPECIAL Well Permit <br /> _. <br /> Pump Inspection By Date O WAIVER Received <br /> Constructed Well Degth it <br /> COMMENTS W c vrW'- N <br /> 'r 0 <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# WellID# <br /> Codes Info B Cash RemittedService Re uest# <br /> J.00 1 r 3 <br /> .,' _ . �O <br /> EHD 43-02-006 (/(/`yL. WELL PUMP PERMIT <br /> 1/2712005 0 '& <br />