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WELL/PUMP PERMTT co <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 36IEWEBERAVE3"FL-SPOCKEONCA95202 - (209)468-7420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS PI•EL• O, H—)r•12 + L�E/d.!feK a0. CITY/ZIP Lop, 1SL4� y <br /> +F p"I 0,>- 1�0�6.i1�A w o <br /> CROSSSTREEr IGEKH IfPK Rd • APN04 ;l 515 AEAND USE APPLICATIONM <br /> y-Tq <br /> OWNER NAME S•`T• IIrE'4TA Gd'l1EGC PHONE <br /> OWNERADDRESS J 1 J 1 va�l•FA' 1f"/C CITV/STATEZEIP STCG/LTO/^' 9SZo / <br /> CONTRACTOR ,JF71— �+ .9AJeLiL ow ? ASSOG. iru— PHONE A, -7R <br /> / <br /> CONTRACTOR ADDRESS I�7- I/JDN}J ILIrK� r��'h�I CITY/STATEIZIP G+OO <br /> CO • -/�LyO <br /> SUBCONTRACTOR PHONE <br /> SDBCONTRACTORADDRESS C�ITTYY//STTAT,IEMIP <br /> LICENSE C-57 ❑C-fit E3 D-09 ❑Other NUMBEHJN I(/®AY EXPIMTIONDATE J/�7 O <br /> GEOGRAPWCALINPORMATION: COOrdleaan X Y Township Range_ Section_ <br /> INTENDED USE ❑DomafirrPrivata ❑Irrigntion/Agdculluel CI Industrial ❑Water Quality Monitoring Soil SamplinP/Chaectmation <br /> ❑PublicR at raSvs <br /> HAIRaaOww .m n¢m .menon N.me cr P Fan-a N um asr <br /> TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteetion/Modification ❑Other <br /> �,n pofbodnp <br /> ❑Monitoring Wella) qof wells bd Soil Boring(s)� ❑Geotechnial Norbomyr <br /> ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑CmsaConnection Repair <br /> ❑New Pump ❑Pump Replacement ❑Pum R it <br /> WELL CONSIRUC ION <br /> Drilling Method ❑Mud Rotary ❑Air Rotary Auger ❑Cable Tool ❑Push Point ❑Other <br /> Proposed Well Depth 10-40 A Esavation in diameter ❑Open Bottom ❑Gravel Pack I Gravel Si. in diameter <br /> ❑Conductor Casing in diameter I Conductor Casing Depth ft <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Schad ❑Steel ❑Plastic ❑Stainless St.] ❑Other <br /> Grout Seal Depth FN 1/ ft ❑Neat Cement(941bbag/J-IOgalwarr Jgril ,,,gfNad€e7W4AlAje— Ib1-1,.k mux l 7 gel water <br /> ❑Bentonite(20116 Solids) ❑Manufacturer S,cc%solids % Name/l- n 1wT- ❑Specs on File ❑Specs Submitted <br /> Grout Placement Method ❑Pumped ❑Free Fell [3 Other ❑Retardant/Aceeleetor(no.) GL EI�•H/LLs <br /> PLD Installed Ey ❑Driller ❑Pump Connector ❑ Other <br /> ❑Concrete Pedestal Dlmenatona:WidtM1 ft IcngH—ftTbick_in ❑Chrlaty Box ❑Stove Pipe <br /> POMP ❑Submersible ❑Turbine ❑Other HP Pump Set R 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. 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 /> �1 IMUM 24 HOU ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> SIGNED TIl'LE • DATE <br /> E�4X <br /> lilt <br /> 1 s., __ .-. I I I I I I I I S N O ot I <br /> -r- k O M N L <br /> -I- } .- A `l.k <br /> ITTTT:l IIIr <br /> Application Accepted By LI Ares Employee IDN. <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pumpl ti By Dere ❑ WAIVERReceIVed <br /> COMMENTS /�`' , _ -/ ) �>• +c._ .�'rF� - l /' Z / of Y 7 <br /> PE I SC Received Cheeldl/ Around Per IV <br /> Coda Info B a Remitted Date S.,IceR uestN InvolceN WeII IDN <br />