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V WF ?,/PUMP PERMIT SCANI <br /> I SAN JOAQUIN COUNTY ENVIRONMENTAL,HEALTH DEPARTMEN, 7 <br /> NON-REFUNDABLE PERMIT 304 E WEBER AvE 3""FL-STOCKTON CA 95202 -(209)468-3420 <br /> �.{ CALL(209))9533-7697 FOR IN5PECTfONS EXPIRES I YEAR FROM DATE ISSUED <br /> FlOWNER <br /> RESS ✓ �� S S/T,r� ��u F <br /> `�' /vClTY1ZIP �TREET V .Ariz) APN y- 7�-- CJ <br /> �/ -7 �D 147 PARCEL SIZE I+4-J LAND1 USE APPLICATION#_ <br /> . NAME - I <br /> / �� ry <br /> PHONE Z4/ <br /> �y'^I DDRESS �3� A - Y� <br /> E t CITYISTATUZIP C <br /> Ii f1 CONTRACTOR `� ` , <br /> �1_/fel�wi/l/ d _e, PHON <br /> CONTRACTOR ADDRESS <br /> •+dry/_lCt�[r/ ICTClTY15TATEJZIP <br /> SUBCONTRACTOR <br /> i SVBCONTRPHONE <br /> ACTpR ADDRESS •� <br /> CITY/STATPJZIP Z - <br /> LICENSE .❑C-57 C-61 ❑D-09 Q'Dlher �J f y <br /> F <br /> Z , EXPIRATIONDATE GEOGRAPHICAL INFORMATION: Coordinates X INTENDEDUSe Y Township3-� Range�r� Section e <br /> Domestic/Private ❑IrngationlAgricultural ❑Industrial <br /> ❑WatcrQua2ityMonitodng ❑SoilSampling/Charactenzatian C <br /> [:I <br /> Public Water System <br /> DUft'd <br /> W from Owner: amr yatem ame <br /> on:acr ame or ane um er <br /> F TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification ❑Test Hole ❑Other <br /> L7 Monitoring Well(s)_#of wells L7 Soil Boring(s) M ofb my <br /> 0Geoteehnical rlofbonncs <br /> E?Well Destruction ❑Out-Of-Service Well r <br /> 'Ne'Pum ❑Pum Re lacement D Out Well Renewal <br /> WELL CONSTRUCT ION ❑Pum Repair ❑Cross-COnneetiunR air U <br /> ! Drilling Method q Mud Rota - <br /> ry ❑Air Rotary ❑Auger ❑Cable Tont ❑Push Point ❑Other <br /> Proposed Well Depth R Excavation <br /> in diameter 0 Open Bottom 111 Gravel Pack I Gravel Size <br /> ❑Conductor Casing in diameter I Conductor Casing Depth _� in diameter <br /> Well Casing Diameter�in ThicknesslGauge/ASTM Scbed Q <br /> ` Grout Seat Depth n ❑Steel q plastic 1:3 Stainless Steel q Other ly <br /> ❑Neat Cement(94!h bag/S-lobo!wafer) ❑Sand Cement <br /> ( ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name .ruck mix 17 gal water <br /> Grout Placement Method ❑Pumper ❑Free Fall ❑Other ❑Specs on File ❑Specs Submitted <br /> ❑Retardant I Accelerator{name) <br /> PEDESTAL Instal]ed 8y ❑Driller ❑Pump Contractor <br /> lirCancrete.Pedestal Dimensions: Width Other <br /> ft Length-B Thick_-e; in ❑Christ Be.PUMP ubmersible ❑Turbine ❑Other Y ❑Stove Pipe <br /> .i -- HP_.� Pum Set IIate <br /> ! HEREBY CERTIFY-THAT I HAVE PREPARED THIS APPLICATION AND THAT THEW P ft Standing Water Level <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS, I ALSO CERTIFY THATK WILL BE DON IMY REQUIRED LICENSE IS <br /> i� <br /> F,' <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKER$COMPENSATION LAWS. <br /> NIMUR4 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> SlGNED <br /> TITLE DATE <br /> F <br /> F4 <br /> ti <br /> G L)� <br /> f~ <br /> l D P R T M E N T USE O N L Y <br /> ' <br /> Application Accepted By D <br /> Date__ O Area �j�y <br /> Grout Inspection — —�L Employee ID# <br /> Date ❑ SPECIAL Well Permit <br /> Fl?estruclion <br /> Pump Inspection By s(, > ? <br /> � ' " Date � ❑ WAIVER Received <br /> inspection By Dare Constructed Well Depth <br /> �uMMENTS _ft <br /> PE SC Received Chec Amount <br /> 'odes info B Cash Date Permit! - <br /> 111 D Remitted Service Re uest 4 Invoice# Well ID# <br /> 5_0 <br /> i +4)o2-OaM1 <br />' M04 <br />