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WELUPUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT (100 EAST MAJN STRUT-STOOMN CA 95202 <br /> NON-REFUNDABLE PERMIT (209)458-3420 <br /> CALL 209 953-7897 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS _/Zoo/ FA <br /> '1 ��7 CITYMP I <br /> CROSS STREET • !T APN 20�0.�v D� p' <br /> PARCEL$ Lmo OSE APPLICATION# g <br /> OWNERNAME Ire <br /> PHONE <br /> iOWrIER ADDREas /1�Zlv_z -I ��������j�'L-. _ ._` CITYI$TATEILIp A - <br /> CONTRACTORLe YIAiQL� _ZeA� . <br /> i <br /> CONTRACTOR ADDREas CItY/STATEMP <br /> SUBCONTRACTOR — 1CdZ6 I -+d PHONE Alf. *A'S.1F 71A <br />` SUBCONTRACTOR ADDRESS W,942 <br /> — <br /> CmISTATEILP <br /> LICENSE )(6-57 0 C-61 ❑D-09 0 Other NUkst:R [._S(p?SA] E)tpIRATIDN DATE <br /> � GEOGRApi11CAL1NFORMAT1pN: Coordinates X Y 7ownship� Range Becton <br /> Q <br /> ClDamestdPriYate ❑inlgationlAgricultutal 13 Industrial 0 Water Quality Monitoring ❑Soil Sarnpling7CharagerfZa6cn <br /> ❑Public Water System <br /> rfUftw%"M Owner <br />' MRa N8Meor PhDne um <br /> ❑NOW Well ❑Replacement Well ❑Wait Altaration/Modillication D Other <br /> ❑Monitoring,Well(s) #Of wells 0 Soil Boring(s} °Of ho`l'd' it or borings <br /> ❑out-4f-Service Well ��o nical <br /> ❑Out-0f-Service Well Renewal ❑Cross-Connection Repair !- b� ^� <br /> 0 New Pump O PuW Re lacemant ❑Pume Repair <br /> Drilling Method Mud Rotary ❑Air Rotary yAuger ❑Cable Tool 0 Push Point 0 Other <br /> Iz <br /> f P71 roposed Well Depth ft Exoavadonin diameter 0 Open Bottom 11 Gravel Pack/Gravel Size In diameter <br /> 11 Conductor Casing in diameter / Conductor Casing Depth ft .� <br /> + wa11 Casing Diameter ThicrnesslGauga/ASTM Sched p Steel ❑Plastic 0 Stainless Seel ❑Other <br /> I Grout Seal Depth ft Neat Cement(94 16 bag15.10 gal water) ❑Sand Cement sac:lNmirn gal water <br /> 0 Bentonite(2096 sDsds) ❑Other16y <br /> Grout Placement Method ❑Pumped ❑Free Fall 0 Other O Retardant I lerator( me) <br /> PEDESTAL Instatied By ❑Driller 0 Pump Contractor 0 Other <br /> ❑Concrete Pedestal Dimensions:Width R Length ft Thick In 0 Christy Boz ❑Stove Pipe <br /> I'k 0 Submersihle0 Turbine ❑Other HP Pump Set.ft Standing Water Level ft <br /> A 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 <br /> WORKERS COMPENSATION LAWS. BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> MINIMUM 2/HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> SIQNEp Tmr. <br /> 2 <br /> M <br /> E <br /> f Y7 <br /> b <br /> I <br /> r <br /> -P' 'R'T M`E1N-T-"li'S-E-0 N'L'Y'°`' <br /> Application Accepted <br /> Data Area Employee 1D#_jgY <br /> Grout Inspettion By Date 0 SPEdAL Well Pertnit <br /> i <br /> Pump Inspection By Date 0 WAIVER Received <br /> "'•SoilSuing Im 1 By Date 5 /� Constructed Wall h <br /> COMMENTS fr- <br /> ? PEC ReceMed Ch.kW Amouflt <br /> Codes tnfn BCash Remitted Date S—ARePer"I uest# Imro. 'Well IDN l <br /> Z S� -Tv3 3 D S 59��6 <br /> it <br /> BR&07 W9LI(PUMP PERMIT . <br />