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WELL/PUMP PERMIT <br /> SAN JOACUM COUNTY ENVIRONMENTAL HL.- DEPARTMENT 600 EAST MAIN STREL.s rOCKTON CA 95202 -(209)469_3420 <br /> NON-REFUNDABLE nPERMIT 1 1 CALL(209)953-7697 FOR INSPECTIONS EXPIRES' O <br /> 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS l"1 vN. �I R�IJ CITYMP <, LITTON 1'l'J JZI Z N <br /> p{�I L,p{ In <br /> CROS$$;)FEET (�ZF}'T I'A I LCL APN I,J 1 OZD S�PARCEL SV-E,-_n-L�LAND USE APPLICATION <br /> OWNER NAME <br /> PHONE _ <br /> OWNERADDRESs ZQ`L-'Z,r G. CpyVhSTD[ 1L CLI6 . _ CrTYISTATEIZIP DC.K^rr� I CFA LIS <br /> 'CONTRACTOR !J�_ Q, -(J(Z�rCLS,Or-� S ihSCM i14TE� _ PHONE -Loq- Tj6-1 3101 <br /> CONTRACTOR ADDRESS !91n- CrtYISTATE21P LQD 1 [ Jf♦` -I' Z.� <br /> SUBCONTRACTOR PHONE__ <br /> SUBCONTRACTOR ADDRESS _ CITYISTATE2IP �J <br /> LICENSE XC-57 ❑C-E1 LI D-09 tl Other NUMBER -1�Q EXPIRATION DATE. � D <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section_ <br /> INTENDED USE U DOmeSbC/Private. C Irrigation/Agricultural C Industrial F Water Quality Monitoring XSoil Samp!inglCharacterizatien <br /> D Public Water System <br /> If different from Owner. <br /> TYPE OF WORK L7 New Well r.Replacement Well L Well Alteration/Modification V Other <br /> 0 Monitonng Well(s) owells L Soil Borin Aotlxxl s ng <br /> —# f ll <br /> g(s) � °�GeOtechniWl Z� not tori s <br /> :7 Out-Of-Service Well 7 Out-Of-Service Well Renewal r Cross-Connection Repair <br /> L New Pump C Pump Repiacement ❑Pump Repair <br /> WELL CONSTRUCTION <br /> Drilling Method -,Mud Rotary C Air Rotary XAuger D Cable Tool C Push Point -i Other <br /> Proposed Well Depth }p -1S ft Excavation_10 in diameter G Open Bottom ❑Gravel Pa(kJGravel Size__ in diameter <br /> i Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in ThicknesslGaugeJASTM Sched ❑Steel D Plastic :j Stainless Steel Other <br /> Grout Seal Depth it ❑Neat Cement!94 Ib bag/5-10 gal water) D Sand Cement __sack.mlxJ7 gal water <br /> ❑Bentonite(20%solids) 90ther Sc,lt- ( ti C,0 4toLf- (,i-"w x.r. 6r.w. <br /> Grout Placement Method ❑Pumped Free Fall ❑Other L7 Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller ❑Pump Contractor / Other <br /> D Concrete Pedestal Dimensions,Width F hIngth _ft Thick in LI Christy Box L Stove Pipe <br /> PUMP ❑SUbmerslbleL Turbine 7 Other li) llor Pump Set ft 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 15 <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 UM <br /> AWS.MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> SIGNED ,v TO. 3 EL-T DATE <br /> ek POR. SECS 3 & 4 T.2N. R.7E., M.D.B.&M. 089-02 <br /> �53 r <br /> 10 <br /> Iml 13 21 lot <br /> La <br /> lit <br /> A N CILMT WLL �y0 N M <br /> 3 y <br /> i <br /> RM <br /> J�EMENT USE NLYApplication AcceptedDate Area Employee ID#tegg <br /> _��-- roa�InspectionBDate_ ❑ SPECIAL Well Pe6mlt <br /> Pump Inspection By Date _ ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS�?C�c7d/ice` / ).L���lt. .lGlrfl'rI �G`_-7L �� �f� cr>/IGC.r.» <br /> PE Sc ReceivedChec Amount Permit/Date i Irrvoicep WaIIID# <br /> Codes Info B ash Remitted Service Request# _ <br /> 501 <br /> END 4308 W ELL 1PUMP PERMIT <br /> 92&07 <br />