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WELL It PUMP PERMIT y SAN JOAQUIN COUN'PY ENVIRONMENTAL HEALTH DEPARTMENT 304E WEBER AvE P°FL-SrocKTOn CA 95202-(209)468-3420 NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED JOBADDRESS t✓l'me4 -PsD CRY/ZIP L;&4A,, 64 9523( D CROSS STREET A wAy Z//l APN (lKJ7-300—ICXARCEL SIZC3„`' LAND USE APPLICATION ft m I / OWNERNAME Pt�/� PHONE OWNER ADDRESS ,,,�((((��'''' / ,/ ® CMISTATE/ZIP W5&A, [114- c_, 9507 CONTRACTOR C��/ t/� _�`/PHONE�i 3/ 'P/y 5/736/ CONTRALTOR ADDRESS // �Tl r CITV/STATEJZIP ^J/9G7 SUBCONTRACTOR PHONEZ0(Q 2-34 Z . SUBCONIAACTORADDRESS CITY/STATEZIP LICENSE -57 ❑Cfil OD-09 13 Other NUMBER' 12 F I EXPIRATION DATE GEOGRAPHICALINFORMATION: Coordinates X Y Township Range_ Section_ INTENDED USE matio'private ❑Inigation/Agricultual ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Chara.a:d.tion O Public Water Stem Ifmn.mmfmm�wec.. ams ysum aaw nWtN.mcwrowxNun,bcr TYPEOF WORK New Well ❑Replacement Well ❑Well Alleration/Modificate. ❑Other ❑Monitoring Wells) gorwells ❑Soil Borings) Salton., ❑Geotxhnical J.ftorim ❑Out-Of-Service Well ❑Out-O&Servicc Well Renewal ❑CroM-COMectlOn Repair ❑New Pump ❑Pump Replacement ❑Pump Repair yr WELL CONSTRUCTION W Drilling Method ❑Mud Rotary Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Other O Proposed Wall Depth, e9C1 R E... tion rp__ Q_in diameter ❑Open Bottom Gavel Peck/Gavel Size in diameter ❑Conductor-Casing indiameter / Conductor Cesing Depth R Well Casing Diameter (p in Thickness/Gauge/ASTMSched ❑Steel *Pl..f. 13Stainleve Steel ❑Other J Grout Seal Depth Y_g 350 it ❑Neat Cement(94 lb bag/J-10gal wafer) Send Cement /Q• 1J sack mix 17 gel wear ❑Ben muke(2W/o solids) ❑Manufacturer Spec%solids_% Name ❑Specs on File ❑Spas Submined Grout Placement Method ❑Pumped ❑Free Fall ❑Other ❑Retardant I Accelerator(name) m PEDy Installed By ❑Driller ❑Pump Contractor ❑ Other ❑Concrete Pedestal Dimensions:Width R Length fl Thick in ❑ChrLty Bax O Stave Pipe PUMP hareaible ❑Turbine ❑Other HP /� Pump Set R Standing Water Level it r` 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN j e JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS F}?a CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. MI>tWM 24 IJOUR ADVANCE NOTICE R•, U/JIIIRED FOR INSPECTIONS I SICNE� ( � /./�/ TITLE /J.Ci - DATE ,-22—.0 K/ n O d M P Application Accepted BY 'ie '7 °6 Area Employee IDg737y W Grout Inspection By .. s __ Dao Q{1 /7/d b ❑ SPECIAL Well PerIBIt U/ Pump Inspection BY- Dene ❑ WAIVER Received I Constructed Well Depth R COMMENTS d, 04 a �) 'I 2 PE SC Received Cher Amount PerMU Codes Info BY Cue Remitted Date Servitt H uestIRvolttg We111Dg U v 3 66 ;R W ZivPco z 3 -7 ,�'i