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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTHRWELL / PUMP PERMIT <br /> NT <br /> NON-REFUNDABLE PERMIT344 E WEBEI „E 3R°FL_ t c t <br /> CALL 11,2(19953-7697 FOR INSPECTIONS <br /> 468-3420 <br /> EXPIR <br /> "7 17' <br /> MDA ISSUED <br /> JOB�ADDRESS ! r � � <br /> CITY/ZIP <br /> CROSS STREET APN Z�f� U,90 <br /> PARCEL SIZE LAND USE APPLICATION# V <br /> OWNER NAME <br /> 21 PHO � � Z d1 y <br /> OWNER ADDRESS J 1 f <br /> CITY/SI C1TATE/ZiP <br /> CON'T'RACTOR <br /> PHON 9 -c <br /> CONTRACTOR ADDRESS <br /> SUBCONTRACTOR CITY/STATE/ZIP <br /> PHONE i <br /> SUBCONTRACTOR ADDRESS <br /> CITY/STATE/ZIP <br /> LICENSE ❑C-57 ❑C-61 ❑D-09 Other {�?, '7 7 � <br /> v NUMBER G�f EXPIRATION DATE <br /> GEOGRAPHICAL INFO MATiON; C40rd1Rates X _ <br /> Y Townshi i <br /> NTEN ED E omestic/Private Irrigation/Agricultural P Range Section <br /> ❑Industria] ❑Water Quality Monitoring ❑Soil Sampling/Characterization <br /> ❑ ublic Water System <br /> ffditTercntfrom caner: <br /> ater ystem Name <br /> ontactame or Phone um r { <br /> TYPE OF 13 Now Well 13 Replacement Well 13 Well Alteration/Modification `I <br /> 13 Monitoring ❑Other <br /> S Well{s)��#of wells 13 Soil Boring(s) #of borings #of borings <br /> ❑Out-Of-Service Well �— ❑Geotechnical g <br /> ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> ❑New Pum Pum R lacement ❑Pum Re air <br /> WELL CONSTRUCTION <br /> Drilling Method ❑Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool <br /> ❑Push Point ❑Other <br /> Proposed Well <br /> Depth ft Excavation in diameter ❑Open Bottom <br /> ❑Conductor Casing p IJ Gravel Pack 1 Gravel Size in diameter f0 I <br /> g in diameter / Conductor Casing Depth ft + <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑Steel ❑Plastic ❑Stainless Steel O Other n <br /> Grout Seal Depth ft ❑Neat Cement(941b bag/3-l0 al water) <br /> ) ❑Sand Cement ss <br /> [3Bentonite(20%solids) ❑Manufacturer Spec%solids % Name sack mix/7 gal water <br /> Grout Placement Method ❑Pumped ❑Free Fall ❑Other ❑Specs on File ❑Specs Submitted '" <br /> ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑ Other <br /> ❑Concrete Pedestal Dimensions:Width ft Length <br /> g ft Thick in ❑Christy Box ❑Stove Pipe y <br /> PUMP Submersible 13 Turbine ❑Other` HP <br /> Pump Set ft Standing Water Level g <br /> I HEREBY CER 1PY 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 N <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. }} <br /> MIN UM 4 HOUR' VANCE NOTICE REQUIRED FOR INSPECTIONS P <br /> SIGNED <br /> TITLE rI j} <br /> DATE <br /> i <br /> r. <br /> UN G <br /> vl0 F <br /> 1) <br /> fu�i!Itm <br /> 1 DEPARTMENT�EOApplication Accepted ByDate Area Employee ID# GK`S <br /> Grout Inspection By <br /> Date ❑ SPECIAL Well Permit <br /> Pump Inspection By <br /> Date ❑ WAIVER Received <br /> Constructed Well pth i <br /> i ft <br /> `MMENTS -?p <br /> r SC Received Cheek# Amount <br /> InfoB ash Remitted Date Permit/ i <br /> _tsC Service Re nest# Invoice# Well ID# <br /> WELL PUMP PERMIT <br />