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v7 �✓ Aerr-.T <br /> ZWELL / PUMP PERMIT _t���Jpqt -,�_oappp,���py <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WESER AVE 3s"FL-S OCKTON CA 9�7gvMl�iltUR• r''" <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED <br /> m <br /> JOB ADDRESS ")L+. l - T'z�=E.10 L.'s- CITY/LIP <br /> � l a <br /> � PN�L,�) AZO01-1 sC-t,2_ ,. AcL <br /> CROSSSTREET _�'� ✓ ! PARCEL SIZE 1 AND USE APPLICATION# <br /> OWNERNAME turd 4 - a�. ..f. �.�l,aVstc — __ PxurvE__L y <br /> OWNER AUnRENN '�.f�R55 S I,, . sCA f <br /> �r•�`�+� CITY/STATE/ZIP <br /> CONTRACTOR i�n�r�1�\?y^- 'y PLS- _ PANE-A �TZ3 3 <br /> CONTRACTOR ADDRESS��m' `,,rpT���.11�1 l�h&-JL. SC 3gO CITV/STATFJZIP xBtS336 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS /CITY/STATE/ZIP_ ._ <br /> LICENSE 7 ❑C-61 ❑D-09 ❑Other NUMBERNG'Z�5.3 A{' EXPIRATION DATE<Z' -3e-Qom' <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section_ <br /> INTENDER USE ❑Durnatic/Private ❑brigation/Agrieultural ❑Indusn-ial ❑Water Quality Monitoring ❑Soil Sampling/Characterization <br /> ❑Public Water System <br /> I(NRerem knm Ow�xr: stir ystem ami C.nuxt Niar.or ane N.. ' <br /> TYPE OF WORT: ❑New Well ❑Replacement Well ❑ Alteration/Modification ❑Other <br /> ❑Monitoring Well(s) _#ofwells oil Boring(s) suflwringscotoehmcal � ' �ufbunng <br /> ❑Out-Of-Service Well ❑Out-Of-Scrvice Well Renewal ❑Cross-Connection Repan' <br /> ❑New Pump ❑Pump Rc lacen3ent ❑Pump Repair <br /> WELL CONST RUCTION <br /> Drilling Method ❑Mud Rotary ❑Air Rotary A91uger ❑Cable Tool ❑Push Point ❑Other <br /> Proposed Well Depth /o-3o' R Excavation in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter <br /> ❑Conductor Casing in diameter / Conductor Casing Depth R <br /> Well Casing Diameter-f—in Thickness/Gauge/ASTM Sched ❑Steel ❑Plastic (3 Stainless Steel ❑Other lV <br /> Grout Seal Depth R )(Neat Cement(9916 bug l5-10gal water) ❑Sand Cement sack mix/7 gal water I <br /> ❑Bcntomu:(20 solids) ❑Manufacturer Spec%solids % Name 13Spcm on File ❑Specs Submitted <br /> 13 /Accelerator(name) <br /> Grout Placement Method ❑Pumped ❑Free Fall Other ❑Retardant 1 <br /> PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑ Other / <br /> ❑Concrete Pedestal Dimensions:Width H Length R Thick in ❑Christy Box ❑Stove Pipe r n <br /> PUMP ❑Submersible ❑Turbine ❑Other HP Pump Set--it Blanding Water Level it .. <br /> V <br /> 1 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 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> /M�1/p1I UM OUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS (S„ <br /> SIGNED r/ TITLE DATE 4 b <br /> - <br /> ��, <br /> e, <br /> y, ILI <br /> t <br /> v <br /> aa*✓ ae 6 ° rYUP <br /> 7 b' I tyro ml <br /> CN7 <br /> Y e now,tirYwWr snWtpr 0 t <br /> -5200 <br /> ..SgNR NDNT N7Y <br /> V <br /> Application Accepted By e4 Dat: Arca Employee ID# <br /> Grout Inspection By Dete� ❑ SPECIAL Well Permit / <br /> Pump Inspection By Date ❑ WAIVERReeelved <br /> Constructed Well Depth R <br /> COMMENTS • di'- ��/o f53te.. '"�tiDs^N/ <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Coda Info B - Remitted Service Request It <br /> ql� OA S2 o b S 4S <br /> EHD 43-02-0 WELL PUMP PERMI1' <br /> 1/3)RW5 <br />