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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3"FL-STOCK <br /> TON CA 95202 -(209)468-3420 <br /> NON-REFUNDABLE PERMIT /s CA/t�L,L. 2ys0.91953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED <br /> GJ \I 6- rl_1C/l�t r 7 rt}� CITY/ZIP t m <br /> JOB ADDRESS Q �IZ Y <br /> GjQ Lc � 'rJ�l I O5� 37-- o <br /> 0 <br /> CROSS STAF.ET V AIN PARCEL SIZE LAND USE APPLICATION# A <br /> m <br /> 1 1, {l J Q�� <br /> OWNPHONE 6ER NAME �O_.L�(T� t�„ �f-� <br /> OWNERADDRESS r� J•�!'♦ CITY/STATE/ZIP CJ, y <br /> CONTRACTOR /"'� GI��vS -I LCI l�C PHONE <br /> ,vs 'y:2 <br /> CONTRACTOR ADDRESS lot) (21 T4 1-78 CITY/STATE/ZIP <br /> PHONE <br /> SUBCONTRACTOR <br /> SUBCONTRACTOR ADDRESS CITV/STATE/ZIP <br /> LICENSE *-57 E)C-61 ❑D-09 ❑Other NUMBE"77�b-� EXPIRATION DATE <br /> G-, 7 <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section_ <br /> '$Oomestic/Private ❑Irrigation/Agricultural ❑Industrial [3 Water Quality Monitoring ❑Soil Sampling/Characterization <br /> INTENDED USE , <br /> ❑Public Water System r <br /> -.0 rme or one <br /> �IIf d.fTerent from Owne1. acr ysiem ame um <br /> TYPE OF WORK/u new Well Replacement Well ❑Well Aheration/lvtodificabon ❑Other r of bo-1p <br /> ❑Monitoring Well(s) r of bonn#Of wells ❑Soil Bonng(s) es ❑Geotechnical <br /> ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> ew Pump ❑Pump Replacement ❑Pump Repair <br /> WELL CONSTRUCTION <br /> Drilling Method,0 Mud Rotary ❑Air Rotary O Auger ❑Cable Tool ❑Push Point ❑Other <br /> Proposed Well Depth7_80 ft Excavation_FL, in diameter ❑Open Bottom 1Xbravel Pack/Gravel Size in diameter <br /> ❑Conduct Casing in diameter / Conductor Casing Depth B <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched'LDO 0 ❑Steel ><Plastic ❑Stainless Steel ❑Other <br /> Grout Seal Depth zoo o A ❑Neat Cement(94(h bag/S-/0 gal water) �i $and Cement /0-'3' .suck mix/7 gal water <br /> ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Spas Submitted <br /> Grout Placement Method ,f+T umped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By j&*nl1cr ❑Pump Contractor ❑ Other <br /> y$Concrete Pedestal Dimensions:Width 44 ft Length It Thick in ❑Christy Bos ❑Stove Pipe <br /> PUMP 1"ubmersible ❑Turbine ❑Other HP Pump Set It Standing Water Level ft <br /> 1 HEREBY CERTIFY THAT I 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. I 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 /> MI IMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS e�,[ <br /> SIGNED �i(/ '� TITLE CI{A G�/l DATE 23 <br /> t <br /> FFEI <br /> _.---- - P A R T M E N T U$,E <br /> 2 <br /> Application Acc pted By Dale / Arca Employee IDN _� <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspecti n B Date -�— 0 WAIVER Received <br /> Constructed Well Dppth \ tt <br /> �J <br /> COMMENTS Old V <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info By Cash Remitted Service Request# <br />