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�---�- ` y WELLIPUMP PERMIT <br /> SAN JOAQUIN COUNTY ENcnRCNMENTAL HEALTH DEPARTMENT NO EAST MAIN STREET-!TaOCKTON-CA 95202-(209)4893420 i <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> 5 377 <br /> Jos ADDRESS 1& oa y�GT/. Sc f t��L 1 N2�p�• CrTYfZIP2 9 -- g <br /> CROSS STREET#AAl SD.t_l F�r�- APN?� '- JV`D PARCEL SIZE 4 LAND USE APPLICATION# O <br /> OWNER NAME C• PHONE rc �¢y '► <br /> OWN 1� <br /> FJt ADDRESS Crry/STATEIZIP <br /> CONTRACTOR /✓��- 2,.5 SS OG_ PHONE 67. 370 1 , <br /> COHTRARADDRESS INLIVS-T•/;i /t'L� h CITYISTATEMP <br /> CTO <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITYIST/n <br /> A�TERIP <br /> a LICENSE C-57 ❑C-61 ❑D-09 [I Other NUMBER j& K/ LWIRATION DATE <br /> GeOGRApWAL INPORMAYreN: Coordinates X Y Township_ Range Section <br /> INTTan)EG USE 'U Domest clPrivate ❑IrrigationlAgnoultural ❑Industria{ ❑Water Quality Moniboring Sokl Samyling/Cheracterization _ <br /> D Public Water System <br /> If tliftm%T+om Owren. vWOrSyMom Nanie ams aPhOmNumbir <br /> TYPE OF WORK ❑New Well 0 Replacement Wait ❑Well AlterationtModification ❑Other <br /> ❑MonitoringWell(s) #ofwells Poll Boring(s)—�f YcfbeW' ❑Geotechnical 0ofbofte <br /> ❑Out-OT-Service Weil ❑Out-OfService Well Renewal ❑Cross-Cannecdon Repair <br /> U New Pump 0 Pum Ra lacement ❑Pump Repair ❑Raise Wen Casing <br /> WELL,CONSMUCTION <br /> Drilling Method ❑Mud Rotary ❑Air Rotary x Auger ❑Cable Tool ❑Push Point ❑ Other <br /> Proposed Well Depth 4,6 R Excavation in diameter ❑Open Bottom 0 Gravel PaWGrevel S'Ize kn diameter <br /> ❑Conductor Casing In diameter I Conductor Casing Depth ft <br /> Well Casing Diarneter_in ThldcnesslGaugmIASTM Schad ❑Steel ❑Plastic 0 Stainisss Steel 0 Other <br /> Grout Seat Depth ft Neat Cement(94 lb bag/5 10 0 water) ❑Sand Cement sack mbd7 gal water <br /> ❑Bentonite(20%solids) ❑OVr 601- 7 Ma'I rr �F A-"a -W <br /> Grout Placement Method X Pumped C Free Fall ❑Other ❑Retardant I Accelerator(name) <br /> Installed By ❑Driller ❑Pump Contractor ❑ Other <br /> 0 Concrete pedestal Dimensions:Width tt Longlh ft Thick in ❑Christy Box ❑Stave Pipe <br /> PUMP ❑Submersible❑Turbine U Other HP Pump Set ft Standing Water Level ft <br /> I 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. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MINIMUM 24 HOUR PVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED 4,^; l .:ti_ '�w+++TITLE�?7 �IIr</✓ ..'DATE,2- Z4 2-010 <br /> SKr 2 <br /> x�- �IIr"r--� �� I a ma• <br /> a � <br /> Y <br /> t�=J r <br /> I Application Accepted By���! /sus-e; Go,�ate t7 Axes Employee ID#0 <br /> Grout Inspection By Date Q SPECIAL Weil Permit <br /> Pump Inspection By ❑ WAIVER Received <br /> r <br /> Soil Bonnginspection By 3 i !� Constructed We R <br /> COMMENTS <br /> PE Be Received Amount Parma Codes <br /> WeIIIDlI <br /> Codes Into Date h Remitted Service Request# <br /> ' E1117 L�.06 WELL RUMP PERMTf <br /> ar2arD9 <br />