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< - <br /> yy�� <br /> WELL / PUMP PERMIT - n <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH D*&9(RTMENT 304EWESER)WW3P°FL-STOCKTOk 05202 (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> (^ m <br /> JOB ADDRESS O Sr 1tJ ZIP <br /> CROSS STREET M u,,, ,.T.4 ApN ARCEL SIZE LAND USE APPLICATION# <br /> OWNER NAME =a—t�" AP PHONE <br /> OWNERADDRESS z4i�k` _/I(,D E��Y/I G{I�/'7 fjpy�•Q-,- CITY/STATE/ZIP <br /> CONTRACTOR PHON <br /> CONTRACTOR ADDRESS ! L q ✓`� /EQ� CITY/STATE/ZIP <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE C-57 ❑C-61 ❑D-09 ❑Other NUMBS ZZ--rExPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township _ Range Section_ <br /> INTENDED USE mestic/Private ❑irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization <br /> ❑Public Water System <br /> If different from O,oier Wetnr Systern No= Contact Nanin,or Phone Numbe, <br /> TYPE OF WORKAidlew Well ❑Replacement Well ❑Well Alteration/Modification ❑Other <br /> ❑Monitoring Well(s) #of wells ❑Soil Boring(s) #ofborings ❑Geotechnical #ofbaHngs <br /> ❑Out-Of--Service Well ❑Out-Of--Service Well Renewal ❑Cross-Coonection Repair <br /> ❑New Pump ❑Pump Replacement ❑Pump Repair <br /> WELL CONSTRUCTION <br /> Drilling Method *ud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Other <br /> Proposed Well Depthzz o R ExcavationI.,Z in diameter ❑Open Bottom Gravel Pack/Gravel Sim in diameter <br /> ❑Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter —0 in Thickness/Gauge/ASTM Sched�Q0 ❑Steel "N-�lwtic ❑Stainless Steel ❑Other <br /> Grout Seal Depth /&9 ft ❑Neat Cement(94 Ib bag/5-10gal roarer) ❑Sand Cement sack mix/7 gal water <br /> Poentonite(20%solids) ❑Manufacturer Spec%solids % Name - ❑Specs on File ❑Specs Submitted <br /> Grout Placement Method ❑Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑Driller Vw�ump Contractor ❑ Other <br /> ❑Concrete Pedestal Dimensions:Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe <br /> PUMP ❑Submersible ❑Turbine ❑Other HP Pump Set ft Standing Water Level ft <br /> 1 HEREBY CERTIFY THAT 1 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. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS <br /> N <br /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> SIGNED frf / Ft ��../ TITLE I� l L/T_h DATE 1,Z 5—®7 , <br /> 4 � <br /> 4-111 <br /> 8 <br /> _ J <br /> 1H/ <br /> ly <br /> rf <br /> 1 <br /> IQ A J A UI C UTM <br /> !!EI <br /> T <br /> D PARTMENT USE Y <br /> Application Accepted By Date I J 6 Area Employee ID# � t <br /> Grout Inspection By Date/.2 wco'- ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Constructed Well Depth fn1 D,, It <br /> COMMENTS —JOAo/ % AL �` A0. .<iaa7 bkAmiat. 2J&Ld4� , <br /> ya <br /> PE SC Received Chee Amount Date Permit/ Invoice# Well ID# <br /> Codes Info ash Remitted Service Request# <br /> SP-004 9 4 _ DD 4re�6 <br /> EBD 4142-006 WELL PUMP PERMIT <br /> In7aW3 <br />