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(:WELL 1 PUMP PERMIT oN CA 95262 - [2�146s- lxo <br />SAN ]OAQUIN COUNTY EN VIRONMBNTAL HEALTH DEPARTMENT' <br />364E WESER AVE S - "ft <br />CALL 209)953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED <br />NON-REFUNDAIILE PERMIT <br />C ^-s 33� <br />CITYrzIP �l <br />JOB ADDRESS <br />` APN �tf ! � O ' LIPARCEL SIZE �- -SLAND USE APPLICATION# <br />CROSS STREET <br />OWNER NAME <br />`? <br />PHON <br />9 <br />y k CrrY13TATFlZIP / <br />s^• �� <br />OWNERADDRESS <br />PHON <br />CONTRACrOR <br />Z <br />CITY/STATKMP <br />CONTRACTOR ADDRESS <br />PHONE <br />SUBCONTRACTOR <br />CrrY/STATETLIP <br />SUBCONTRACTOR ADDRESS <br />NUMBER &, Expm mbN DATE 0 <br />LICENSE ❑ c-57 ❑ e -6I ❑ D-09 Wothef <br />X <br />Y Township Range Section <br />GEOGRAPHICALIPipORMATIONt Coordinates <br />A Industrial ❑ Water Quality Monitoring ❑ Soil SamplinglCharacteri>ation <br />INTENDED USE Domestic/Private ❑ "gation/Agrieultutal <br />❑ Public Water System <br />Vdifftaent from Llwner <br />Water y6tmt Nam tact otm of room u <br />T ya Oe WORD ❑ New Well 0 Replacement Well <br />❑ Well Alteration/Modificationp ofb❑o er b ofbotiiw <br />❑ Gootechnical <br />13 Monitoring Wells) # of wells <br />E3 Soil Boring(s) <br />❑ Out -Of --Service Well Renewal ❑ Cross -Connection Repair <br />[3 Out -Of -Service Well <br />Cl New Pump Pum R kacement <br />❑Pum RMaIT <br />Trilling Method d Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Took ❑ Push Point ❑ other <br />Proposed Well Depth ft Excavation in diameter E3 Open Bottom ❑ Gravel Pack / Gravel Sizein diameter <br />❑ Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter in Thickness/Gauge/ASTM Schell 0 Slee] ❑ Plastic ❑ Stainless Steel ❑ Other <br />ft ❑ Neat Cement (941b bag / 9-10 gal water) D Sand Cement suck mix 17 gal water <br />Grout Sea! Depth ❑ Specs on File ❑ Specs Submitted <br />C) Bentonite (200% solids) ❑Manufacturer Spec °10 solids % Name <br />;rout Pincement Method E3 Pumped (3 Free Fal] ❑Other <br />❑ Retardant / Accelerator (name) <br />Installed 8y ❑ Driller ❑ Pump Contractor ❑ Other <br />❑ Concrete Pedestal Dimensions: Widtb ft Lengt <br />ft Thick in ❑ Christy Box ❑ Stove <br />TMP <br />ubmersible ❑ Turbine ❑ Other HP Pump Set ft Standing Water Level L \ ft <br />1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br />jOAQUIN COUNTY ICENSE IS <br />CURRENT AND ACT/VE (WITH THE CALIFORNIA A CONTRACTORS SLAWS, AND RULES AND TATE LICENSE BOARD AND THTIONS. I ALSO AT I MT IN CMPLIANCEMy REQUIRED LWITH ALL <br />W <br />ti <br />a <br />