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WELL / PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH Df1!RTMENT 304 E WEBER 3a9 FL-STOCKYSCANNQ NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED y JOBADDRESS 3'101 S. IQ $lvU9h ad CITY/ZIP Hal} 1`I5-23y e yp y �/3 PARCEL SIZE 26�s LAND USE APPLICATION# CROSS STREET W. L/�t^-��✓' �0PS �. APN �q OWNERNAME LC^.1 `�e�`O�JI^'t>•"Ir 11 PHONE//��gJ>-BaU- b°13N OWNER ADDRESS 1� o� 0 31-soli) CITY/STATE/ZIP 5 `% scF,r+ of CONTRACTOR T( f i PHONE CONTRACTOR ADDRESS 3°III 1. Nt (Ae;W CITY/STATE/ZIP 1..)- 5�rya,P/ ^,4g SUBCONTRACTOR Z2�Z/ PHONE SUBCONTRACTOR ADDRESS CITY/STATE/ZIP LICENSE ❑C-57 ❑C-61 ❑D-09 ❑Other NUMBER EXPIRATION DATE GEOGRAPHICAL INFORMATION: Coordinates X Y Township _ Range_ Section_ INTENDED USE ❑Domestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring it Sampling/Characterization ❑Public Water System U`,iQerant from Owner. Water Syseem Nam Contact Noone or Phone Nurobt, TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Altenuion/Modification ❑Other ❑Monitoring Well(s) #ofwells ,Soil Boring(s) —4 #of b.mga eotechnical #ofbonngs U-1 ❑Out-Of-Service Well ❑Out-OR-Service Well Renewal [3Cross-Connecti n Repair 1 ❑New Pump ❑Pump Replacement ❑Pump Repair WELL CONSTRUCTION Drilling Method ❑Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Other Proposed Well Depth ft Excavation 41 diameter ❑Open Bottom ❑Gravel Pack/Gravel Sim in diameter I ❑Conductor Casing in diameter / Conductor Casing Depth It Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑Steel ❑Plastic ❑Stainless Steel Other r),)'J GI-qPr Grout Seal Depth ft Neat Cement(94 Ib bag y 5-10 gal water) ❑Sand Cement sack mix/7 gal water ❑Bentonite(209/o solids) ❑Manufacturer Spec%solids -9/o Name ❑Specs on File ❑Specs Submitted Grout Placement Method ❑Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑ Other ❑Concrete Pedestal Dimensions:Width ft Length R Thick in ❑Christy Box ❑Stove Pipe PUMP ❑Submersible ❑Turbine ❑Other HP Pump Set ft Standing Water Level ft I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS fI� CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL v ' WORKERS COMPENSATION LAWS. O INI UM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS I �/ SIGNED TITLE TA�?r CG��i✓'�r^h� S DATE —az lA7 r N o N SN301, p/ N D F DEPARTMENT USE ONLY