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a+ YELAl L / PUMP PERMIT AWJOA N COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER Ave3"°FL . T bN.CA'i95202 (2Q9)468-3420 UNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES' 'Y FROM DATE:ISSUEp �d A ✓ !J IJ WI 4 1 CITYIZi P D rn JOB ADDRESS r P r :.. v {r t APN U!/ .PARCEL SIZE _ LAND USE APPikX'CION;I CROSS STREET �o OWNER NAMEij�2T-WjPHONEt + OWNERADDRESS, CITYISTATEIZIP +rr ifr CONTRACTOR _:J✓T// U/K/ P CONTRACTOR ADDRESS TATE/ZIP - V.�4 U T ` SUBCONTRACTOR PHONE "5 If - .r -iii 7. S S�rsC.`.,.�'i 'Fx�!•�r: . !I SUBCONTRACTOR ADDRESS CITYISTATE/ZIP : , r, LICENSE ❑C-57. ❑C-61 ❑D-09 ❑Other f NUMBER. EXPIe�fd3�?�f_ 1 ICrtf, f�.'i t.r ILF RATIO[V;YIAT�E li: ,ia GEOGRAPHICAL INFORMATION: Coordinates X Y"'' '' Township" Ra Section INTENDED USE mestic/Ptivate ❑Ir6gation/Agricultural ❑Industrial 13 �SOi Water Quality Monitoring .,,,4Wt3 Sam ling/Characteriration e� . r. .q:` - ,.71 $I$li ❑Public Water ptem .. ; tfdiRerent from wnr:r: ater yslem arm :t..•' '� ontact N. , sK3 um ,�;�-� yr § TYPE OF WORK ew Well ❑Replacement Well ❑Well AlterationlModiftaation "`-❑Test Hale ❑Othe 3r` :"f� 1" " 1`� ;s. 13 Monitoring Well(s) 1of wells 13 Soil Borings) ! .#.ofborings ❑G't j '01:b, N of burin s I=" Fi ❑Well Destruction ❑Our-Of-Service Well ❑Out-Of Service Well Renewal��.., ,1156 51tv, , •. Pu me ❑Pump Replacement ❑Pump Repair' I ❑Cross-Connection R .ti i'afi1fS�31tt1 ?r.'tT "r "�' ` WELL CONSTRUCTION - '•,!)�tj ,r1,t'wi°{` t ll1V.f s';.li ! •= x, Drilling Method ❑Mud R ary Air Rotary ❑Auger le Tool ❑Push Point ❑Other ' _ _J ' 3 .. ,�4�te Proposed Well Depth ti Excavation in iameter} ;, 4pen.Bottom ©Gravel P,ack�/' v I Size'' in diameter ❑Conductor Carving- 1�in diameter / Conductor Casing Depth ft k Well Casing Diameter in Thickness/GaugelASTM Schad ❑Plastic ❑Stainless Stec) ❑Other , Grout Seal Depth fl . ❑Neat Cement(941h hag/5-10gal water)"a and Cement � £ y �t.rI S�3fT•` �.•. is _ suck mix!7 gal water. ❑Bento rte(20%solids) ❑Manufacturer Spec%solids % Name ❑Spn File'f[3 Specs Stfbmitted Grout Placement Method e+@9:Prrrnped ❑Free Fall ❑ T6 Other ❑Retardant/Accelerator{name)'" �" "• � � '- _ t PEDESTAL Installed By oder 0219hR[[ip Crac or - C3 Other ' -' i��'--�t-r-=-•�••-•-- f ncrete Pedestal Dimensions: Width ft Length fi Thick in ❑Chrlity Bo ;❑Stove,Pipe PUMP clalS&tbmersible ❑Turbine ❑Other t l HPL-�W° Pump SetStanding Water Level I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND'THAT THE WORK WILL BE' CORDANCEfWITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. 1 ALSO CERTIFY THA1"..IVL`IAEtEQU1REWLICENSE IS CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM,4W66MPCIANCE WITH ALL WORKERS COMPENSATION LAWS. at.. .�; [Sdt tv. M UM 24 HOUR ADVANCE NOT CE/"�.��QUIRED FOR INSPEC,T�O SIGNED - - LE V k r r 5 } e Ciz rest w 4' r 1! -F :'t' 3' €;�`. `' `' ail ' 'N i �`•� _ a 1 } 17 W b'=-^? i . �'... .; �,�•.' - } fir 2. 'r 07 r. E AR ENT 71 'rit'3 Application Accepted By, ' +f ? +=!;i'S Arca v _1 s Grout Inspection --lex Date ❑ SPEC'14 'e1 Te"Imit l/ p Pump Inspection BY Date 9 ❑..'WAIS . Vedurrl-; Destruction Inspection H� Comm EN •'rtf:. rF': �!}) / I:. PE SC Received Check#/ Amount Date 'Peemitl Codes Info B Remitted ' 5ervtee R nest q v`f iia t a f,We!!IDVF To (D 2_�, r WELL PUMP PERMfT �s�cdLf�`•e-- _ Y