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WELL/PUMPARMIT <br /> SAN JOAQUIN COUNT ENVIRONMENTAL HEALTH DEPARTMENT 3041E WEBER AVE 3"FL-STOCRTON CA 95202 -(209)468-3/20 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED <br /> ' c9 0�l m <br /> JOBADDRESS � R Z.a � '' Cm!!Ar L <br /> CRISIS STREETlleVie; O APN D✓_3-h]N-9( e <br /> PARCELSIEL Z LAND USE APPLICATION# <br /> SURBRNAME PHONEy' ahI-—a <br /> qLt9 <br /> OWERADDRSCITY/STATEJTAPOMCONTMCTOR Ili-Aaf-T A- l PHONE <br /> CONMLTme ADORERS 4 < 7 /7 Cm/STATIOZIP <br /> IXACONTMROR /lad Li IndnClr PHONE 7YS 279 <br /> 7 <br /> SUBCtlNTMCI'00.ADDR 3y Cm/STATEMIP <br /> LICENSE C-57 13C-61 0D3 9 ODther NUMBER 2?-39S EMEATIONDATE G-0 <br /> GRGGRAPHICALINE'ORMAnoN: C.MIMtes X Y Township_ Range_ Section <br /> INTENDED USE ImatirlPdreu D IrtigatioNAgdtultural O Industrial 0 Water Quality Monitoring 0 Soil Ssmpling/Chma¢eriation <br /> O Public Water SKKtem <br /> Irdrtnenl fmm OWMr .m ynem sn eme.r a ° <br /> 1 TYPE OF WORK New Well O Replacement Well ❑Well Altalatian/ModiBa6on 0 Tat Hole ❑Other <br /> ❑Monitoring Well(s)_#ofvmlls ❑Soil Boring(s) 0Gemeehnical xormaao. <br /> 0 Well Destruction 0 Out-0f-Service Well ❑Out-0RServi a Well Renewal <br /> 1 aw ft.2 O Pum R ta em nt O PIDEP Repair O CrossCwnection Repair <br /> WELL ConsraurnoN <br /> Drilling Method W Mud Bogy O Air Rotary 11Auger 0 Cable Twl ❑Push Point 0 Other <br /> Proposed Well Depth t o a R ExcavationI ­L� n diannater ❑Open Bglom ><3nWel Peck/Gnvel Sia in diamekr <br /> OColldmtor mg indianater I Conductor Cuing Depth—��it <br /> 1 Well Cuing Diameter in ThicknessRCauge/ASTM Schad' it p SL Cl Steel '15[astic O Sun 5 0Other <br /> Grout Seat Depih�ft O Nat Cement(94 111 hag/5-10gu1 anded XS.,W Canent A•!5 sack mix/7 gel water k t <br /> ❑Be ttonine(20%wlids) 0 Manufacturer Spec%solids % Name ❑Spea on File ❑Specs Submitted 4:� <br /> Grout Placunent Method ..dumped ❑Free,Fall 0 Otber O Retardant/Accelamor(name) �V <br /> ' PEDE6TAL Installed By ONlier 13 Fump C,,mgE or ❑Other <br /> O Concrete Focused Dimanhus: Width ft ft Thick in OChdaty Bos ❑Stove Plpe <br /> PUMP Submersible ❑Turbine 0Mer HP Pump Set ft Standing WmRr Level fl m <br /> 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> I JOAQUIN COUNTY ORDINANCES STATE LAWS,AND RULES AND REGULATIONS. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE !IKE <br /> WORKERS COMPENSATION LAWS ff <br /> !�""1` M NNIMUM 24 HOUR ADVANCE NOTICEI(EQU[RED <br /> D FOR INSPECTIONS <br /> SIGNED / AM- TITLE V Cd/"6 /`-' DATE <br /> Q. <br /> I^\ <br /> V <br /> i - <br /> 1 <br /> ' N <br /> 1 - DEPARTMENT USE ONLY — Y <br /> �. -AppIkRF0n AccrP 11 Dore ..�.s.e - EL��— Araa,- '— - <br /> Grout Inspation B DateyLa' S ❑ SPECIAL WRIT Permit <br /> I Pump IR P..:.By Date ❑ WAIVER Received <br /> Deswdion Inapedion By Date Constructed Well Depth R <br /> COMMENTS eDL4_J.QT Ul° R-Ec " <br /> ' PE SC Received Chet Amount Date Permit/ 1#vokep We111D# <br /> Cada Info B as Remitted ServlceR uent# <br /> 366 Zxs a,a /.6 -7n <br /> 43d'O Ofi) So oU <br /> END43LE-0a WELL PUMP PERMIT <br /> ay+DT <br />