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WELL / PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DL,ARTMENT <br /> 304EWF.BER,_.E3"v FL-STOCK A Z 68 20 <br /> NON-REFUNDABLE PERMIT CALF(209)953-7697 FOR INSPECTIONS EXPIRES ] Y s <br /> II <br /> JOB ADDRESS <br /> fly CITY/ZIPrm <br /> 3fl -a <br /> CROSS STREET C+I "F' <br /> ! rP P APN zC'S c� C� l�, PARCEL SIZE ]+-� v <br /> LAND USE APPLICATION# <br /> OWNER NAME ¢ S7• S C, - m <br /> PHONE <br /> OWNER ADDRESS CITY/STATE/ZIP <br /> F <br /> CONTRACTOR 321 D <br /> PHONE <br /> CONTRACTOR ADDRESS If CITY/STATE/ZIP <br /> SUBCONTRACTOR <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> It <br /> LICENSE C-57 ❑C-61 I!❑D-09 ❑Other NUMBER <br /> EXPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> Township Range Section <br /> INTENDED USE ❑Domestic/Priva:e X <br /> Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/CharacterWlion <br /> ❑Public Water System <br /> If different from Owner: axr ystem Name <br /> ij, °n[acl ame or one um er <br /> TYPE OF WORK New Well ❑Replacement Well ❑Well Alteration/Modification ❑Test Hole ❑Other <br /> #of borings <br /> ❑Monitoring Wells) #of wells ❑Soil Borings) ❑Geotechnical #of borings <br /> Cl ell Destruction �I ❑Out-Of-Service Well Q Out-Of-Service Well Renewal <br /> New Pum ❑Pum Re lacement ❑Pum Re air ❑Cross-Connection Repair <br /> i <br /> WELL CONSTRUCTI N <br /> Drilling Method N Mud Rotary 13 Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Other <br /> Proposed Well Depth - ft Excavation_i _in diameter ❑Open Bottom Gravel Pack/Gravel Size in diameter <br /> ❑Conductor Casing II in diameter / Cond for sing Depth ft <br /> Well Casing Diameter 8 in ;Thickness/Gauge/ASTM Sched _ ❑SieelPlastic ❑Stainlgss Steel CI Other <br /> l <br /> Grout Seal Depth !I ft C1 Neat Cement(44 l6 hub 15-10 gal water) ❑Sand Cement sack mix/7 gai water <br /> 1* (20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted <br /> Grout Placement Method Pumped I ❑Free Fal l ❑Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By I� 13Dimensions; <br /> Driller ❑Pump Contractor ❑Other <br /> ❑Concrete Pedestal Dimensions: Width ft Length Thick in ❑Christy Box ❑Stove Pipe <br /> PUMP Submersible �� ❑Turbine ❑Other fiP- ✓— Pump Sete ft Standing Water Level ff <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. I 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 rN I' <br /> WORKERS COMPENSATION LAWS` I <br /> N11N,IN11 24 HOUR ADVANCE NOTICE REQ RED FOR INSPECTIONSt I <br /> SIGNED TITLE DATE O -D <br /> 1 l� ,_ <br /> ihfl �c i <br /> 5 S <br /> IM s Y <br /> r � <br /> W <br /> C yI <br /> 7i j ti"li n� Sof . - ,.. � <br /> - <br /> a <br /> IM U T <br /> I� N 4 Cl AE T <br /> A <br /> �M <br /> 7j <br /> i� <br /> &W -- <br /> ✓ D-E,PARTMENT U S ONLY <br /> Application Accepted By I `'�-- Date— Area-2/ 9 _ � L( <br /> Employee ID# �'" � l <br /> Grout Inspection By Date / (o j) ❑ SPECIAL Well Permit <br /> Pump inspection By IM Date <br /> 3 O.Sr ❑ WAIVER Received : <br /> Destruction Inspection By Date Constructed Well Depth ft <br /> COMMENTS �.L %� LC% CF <br /> i <br /> PE SC Received hec Amount PAir <br /> I <br /> Codes Info B Date I� Cash Remitted Servic Request# nvoice# Well 1D# <br /> '{3 4.e& st% zs.tf� 5 �� G` 1 J.�'6 <br /> !i <br /> IY <br /> EHD 43-172-066 I <br /> 816/04WELL,PUMP PERMIT <br />