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WELL I PUMP PERT SCANVED SAN JOAQUIN COU VIRONMENTAL HEALTH DEPARTMENT EWEBER AVE 3-FL-STOCRTON CA 95202 -(209)468.3420 NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED Jos ADDRESS O IV; CI's�� CITV/ZIP A > CROSS STREET CLTt r��J I APN J2�12�jb n�3 PARCEL SIZE /a LAND UsE APPLeCATTION#�gq�7 OWNERNAME C...�✓ 1 //(�J�+l�'/N PHONE (!�7[ v L v OWNERADDRESS .1 r CITY/STATE/LIP iU 1J CONTRACTOR .-C I 4• PHONE + + / r -�� CONTRACTOR ADDRESS &)U2FCITVISTATEIZIP Y /, r S SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS CnN/STATEfZIP LICENSE <C-57 O C-61 O D-09 ❑Other Numn zz36 EXPIRATION DATE GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section 1 p S ntestidprivate 111rrigation/Agricultuml ❑Industrial M Water Quality Monitoring 0 Soil Sampling7Chatacterimtion Cl Public Water system Ifdiffasntfmm Ow at"Syuem Name CoAuat arae of Phone RUM0 TYPE OF WOR{-S joew Well 0 Replacement Well C]Well Alwation/ModificMion ❑Other C3 Monitoring Wells) #of wells O Soil Bodng(s) N of bofings Q Gcosechnical a afam nss ❑Out"-Service Well ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair ew Pump 13 Flump Replacement Q Pump Repair WELL ONSTRU N DrkBkng Method 5ltAvd Rotary O Air Rotary ❑Auger ❑Cable Tao[ O Push Paint O Other Proposed Well.JD�epth ZV _._ft Excavation�,r in diameter ❑Open Bonom VMravel Pack/Gravel Size in diameter ❑Conductor Casing in diameter f Canductor Casin Depth it Well Casing Diameter(:�__in Thickness)GaugeASTM Sched - —- - ❑Steel jKlastic ❑StainlVecl C3 Other Grout Seal Dcpth jrr7ft C7 Neat Cement(941b bag/3-10 gal"ter) -<Sand Ceme , � sack mix 17 gal water O Bmtonitc(20%solids) CI Manufacturer Spec%solids % Name O Specs on File C]Specs Submitted Grout Placement Method ,,Pumped O Free Fall ❑Other 0 RetardantI Accelerator(name) PEDESTAL Installed By oG 7 ler ❑Pump Contractor ❑ Other ❑Concrete Pedestal Dimensions:Width fl Length ft Thick in O Christy Box ❑Stove Pipe Pump ubmersible U Turbine O Othcr HP Pump Set ft Standing Water Level -ft 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION D THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS SIGNED��( /J �.L..w TITLE C•C� DATE Lk I S MiF 4 DE ARTMENT SE ONLY Application Accep y Date Area Emptoyee IDN ; t Grout Inspecti By Date i�L 13SPECIAL Well Permit Pump Inspection'- ❑ WAIVER Deceived Constructed Wall Depth...... ft — COMMENTS{*,I7 f3F {L�{t t7 PE SC Received ckglw Amount Date Permit! Invoke N Well 1D# Codes Info B Cash Remitted Service R nest# >r1a o U) as a&4/IS Oil)43-02-1M WELL PUMP PERMIT UVW05