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WELL/ PUMP PERMIT�, r f <br />SAN JOAQUIN C UNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3'° FL- STAd1 9) 468-3420 <br />NON R NDABLE PERMIT CALL (209) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS —{ f/r9 J CITY/ZIP_ A <br />CROSS (STREET V APN Ub�3 1 P5p— IV t1 PARCEL SIZE LAND USE APPLICATION # <br />OWNER NAME _ f_Wj PHONE <br />OWN FR ADDRESS <br />CONTRA CTOR y � <br />CONTRACTOR ADDRESS <br />SUBCONTRACTOR <br />ADDRESS <br />LICENSE ❑ C-57 ❑ C-61 ❑ D-09 ❑ Other NUMBER <br />GEOGRI PHICAL INFORMATION: Coordinates X _ Y <br />CITYISTATE/ZIP <br />PHONE V - I . / ' 2,p <br />CITY/STATE/ZIP 4'1r <br />PHONE <br />CITY/STATE/ZIP <br />EXPIRATIONDATE <br />Townshin R.— Snorin. <br />INTENDED USE <br />omestic/private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring • ❑ Soil Sampling/Characterization <br />Date Permit/ <br />Service Request # <br />❑ Public Water System <br />If differenI from owner: <br />,1 <br />aier System Name ContaCl ame Or one um er <br />TYPE OF <br />WORK <br />ew Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Test Hole ❑ Other <br />❑ Monitoring Well(s) #of wells ❑ Soil Sorin s 4ofborings kOtborings <br />gO ❑ Geotechnical <br />❑ Well Destruction ❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal <br />Pum ❑ Pum Replacement ❑ Pump Repair ❑Cross -Connection Repair <br />WELL CONSTRUCTION - - <br />Drilling Method <br />Proposed Well <br />❑ Mud Rc4ary Air Rotary 0 Auger ]e Tool ❑ Push Point ❑ Other <br />Depth D 29�— ft �Ccavation in iamd eter VeQpen Bottom ❑ Gravel Pack / Gravel Size in diameter <br />❑ Conductor Ca 'ng � in diameter / Conductor Casing Depth ft <br />Well Casing <br />Diameter in Thickness/Gauge/ASTM Sched.__ �] ❑ Plastic ❑ Stainless Steel ❑ Other <br />GroutSeal <br />Depth ft ❑ Neat Cement (941h bag/S-10gu1 wafer) and Cement —sack mix 17 gal water <br />❑ Bento ite {20% solids) ❑ Manufacturer Spec % solids % Name ❑ Specs on File ❑ Specs Submitted <br />Grout Pilacement Method ol+nped ❑ Free Fall ❑ Other. ❑ Retardant / Accelerator (name) <br />PEDESTAL <br />Installed By 0411:&41aer o046amp Contrac or ❑ Other <br />ncrete Pedestal Dimensions: Width ft Length ft Thick in ❑Christy Box ❑Stove, Pipe <br />PUMP <br />t�Submersible ❑ Turbine ❑ Other HPLC 0 Pump Set J�`ff Standing Water Leve] '41 <br />I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN' ACCORDANCE WITH SAN <br />JOAQti1N COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. [ ALSO CERTIFY THAT MY REQUIRED- LICENSE 1S <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 UM 24 HOUR ADVANCE NOT CE 47 <br />FOR INSPECTIONS <br />SIGNED �1 E e DATE <br />E AR'ENT US O 'LY <br />Application Accepted By Area �� 2 Employee 1D# <br />Grout Inspection Gs„' Date /��/��j❑ SPECIAL—Well Permit <br />PI mp Inspection By Date ❑ WAIVER Received / <br />Destruuctioonn Inspection B 50eC � <br />COMME222 Z <br />N"� <br />PE <br />Codes <br />SC Received Check#/- Amount <br />Info B Remitted <br />Date Permit/ <br />Service Request # <br />Invoice Wll1p# <br />e <br />,1 <br />3 2 <br />SM <br />S - 411o2-0 <br />QI X04 a. <br />8 <br />EHD 43-02-006 <br />9/6/04 WELL PUMP PERM17 <br />