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WELL/PUMP PERMIT` <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL 1. R DEPARTMENT 304 E WEBER AVE 3"0 fOCKTON CA 45202 -(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 I:OR TNSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> rn <br /> JOB ADDRESS p p 'CITYIZIP Q+ <br /> CROSS STREET ►n ! 0 i APN L, �!�Y(1�I \PARCEL SIZE trru___re_.rr`LANp USE APPLICATION# <br /> ---- r^ rn <br /> OWNER NAME f�4CJ TTi �_p_ /_SIFP�J ��p��� �� PHONE q.� 'A <br /> OWNER ADDRESS,)r, d aX /&, 0p (� Crm1STATLfZjP f'_P- JJJ/��, Gad 61 <br /> CONTRACTOR k 1e4a�P Id e-r , Iiia- ,� __ „-„� PHONE xo —_`i4L ^I-3,1 <br /> CONTRAcrOR ADDRESS,q57%S: --&A y,r f`(.P CITYISTATElZ1P <br /> SuwONfRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS C� F7 !ITY1SST72-ATFJZIP <br /> 13M <br /> LICENSE C-57 ❑C-61 D-09 ❑Other NUBER Y .-Z EXPrRAT10N DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y - Township Range Section <br /> INTENDED USE O Domestic/Private LT lrrigationlAgricultural O Industrial 0 Water Quality Monitoring Sail SamplinglCharaeterizalion <br /> O Public Water System <br /> Ifdilf—i Rom Omer: W.I. yRem ame CaawiNsreorflhcnI <br /> TYPE OF WORK 0 New Well O Replacement Well O Well Alteration/Modification Q Other <br /> *Monitoring Wel]{s) #ofwells O Soil Boring(s) aofborinp ❑Gcatmhnical YJof6armyp <br /> *Out-0FService Well ❑Out-Of-Service Well Renewal O Cross-Connection Repair <br /> ❑New Pum O Pum R lacareent [3 Pump Repair <br /> WELL CONSTRUCrtON <br /> Drilling Method El Mud Rotary O Air Rotary 0 AugcT ❑Cable Tool ❑Push Point I7 Other <br /> Proposed Well Depth-_--Z�o ft Excavation (42 in diameter 0 Open Bottom ❑Gravel Pack 1 Gravel Size in diameter <br /> 0 Conductor Casing in diameter l Conductor Casing Depth R <br /> Well Casing Diameter_in ThicknesslGaugeIASTM Sched 0 Steel 0 Plastic 17 Stainless Steel ❑Qtheer <br /> Grout Seal Depth ft 1]Neat Cement(941b bag/J-lOgal water) E3 Sand Cemen 04014 0- S;k mix 17 gal water <br /> O Bentonite(209A solids) 17 Manufacturer Spec%solid&_% Name ❑Specs on tie Specs Submitted <br /> Grout Placement Method 17 Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑ Other <br /> ❑Concrete Pedestal Dimensions:Width R length ft Thick in ❑Christy Box 17 Stove Plpe <br /> PUMP ❑Submersible ❑Turbine ❑Other HP Pump Set ft Standing Water Level ft <br /> I HEREBY CERTIFY THAT 1 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 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 /> M NIfNU 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> SIGNED `�--�ti_ TITLE DATE <br /> v' <br /> It i <br /> i <br /> I <br /> i <br />� r <br /> El AP Wfill <br /> DEPARTMENT USE ONLY dJ <br /> Application Accepted By Date Area Employee 1D# _ <br /> Grout Inspection li Date ❑ SPECIAL Well Permit <br /> Pump Inspection By Pate ❑ WAIVER Received <br /> Constructed Well Depth ft <br /> COMMEN - <br /> PE SC I Received Check#! Amartint Date Permit✓ Invoice# Well IDN <br /> Cedes Into B Remitted Service Request# <br /> L .'Sti 2701tp Z 0 <br /> EHD 4343-006 WELL PUMP PERMIT <br /> In7r=0s <br />