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WELUPUMP PERMIT <br /> SAN JoAoutN CouNry ENVIRONMENTAL HEALTH DEPARTMENT 800 EAST MAIN STREET-STocKToN CA 95202-(209)488-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> y <br /> Joe ADDaEss 316,00 <br /> CnTdZrP TRReV 95304 <br /> ,/ ! 0 <br /> CROSS STREET tt APN PARCEL SIZE I -LAND USE APPUCATIICHt m <br /> OWNER NAME AVar C..8Aq T' ' PHONE 2oq- 83-5- /l71 <br /> OWNER ADoRESS CRHSTATFILP <br /> CONTRACTOR PHONE <br /> CoNTRAcTOR ADDRESS CRYISTATEfZIP <br /> SUBCONTRACTOR PWME <br /> SuBcowmACToR ADDRESS CfT/ISTATFJZIP <br /> LICENSE C C-57 ❑C-61 0 D609 0 Other NUMBER ExPIRAnoN DATE <br /> GEOGRAPHIcALINFORMATION: CoofdinatSSX Y Township_ Range Section, <br /> INTENDED UsE IILDomesticefivate C ImgetionlAgriadtural D Industrial D Water Quality Monitoring 7 Sail Sampfng/Character¢alion r <br /> D Public Want SYs� eme or <br /> It dNrerd Som x?._ a Sara <br /> TYPE OF WORK I I New Well 1 1 Replacement Wen I I Wen Atteration/Modification I I Other <br /> 0 Monitoring Well(s) f of weft C Sod Boring(s) 0 of tennis 7 Geotechnical s af tdd ps O <br /> 0 Oul-OfServlce Wen C Out-O/-Service Well Renewal C Cmss-Connection Repair. <br /> 9 New Puny 7 Pump Replacement 0 Pump Repair 7 Raise Well Casing <br /> WELL CONSTRUCTION _ - ---- - <br /> Drilling Method C Mud Rotary -1 Air Rotary C Auger 7 Cable Tad ❑Push Point ❑ Other r ,� <br /> Proposed Wen Depth R Excavation in diameter C Open Bottom ❑Gravel Pack/Gmvel Size In diameter <br /> 0 Conductor Casing In diameter / Conductor Casing Depth R <br /> Well Casing Diameter,in Thickness/Gouge/ASTM Sched J Steel C Plastic ❑Stainless Steel C Other <br /> Grout Seal Depth R 0 Neat Cement(94/b bage'5-10 gal Water) C Sand Cement sack mixf7 gal water <br /> ❑Benionfte(20%sofds) 7 Other <br /> Grout Placement Method a Pumped L Free Fan L Other ❑Retardant/Acceldator(name) 0 <br /> PEDESTAL Installed BY C Driller C1 Pum Contractor C Other <br /> C Concrete Pedestal Dimensions:Width R Length R Thick in 0 Christy Box C Stove PIP* <br /> P MP SubmersibleC Turbine 0 Other HP //2-. Pump Sal 2- R Standing Water Lavei R <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 <br /> WORKERS COMPENSATION LAWS. <br /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS O� <br /> S b Trrcf !T t'!C e �IQQQ�' DATE 10 Z--3 0 / <br /> is <br /> O NX <br /> C) <br /> DEPARTMENT US ON Y <br /> Application Accepted By d y Area Employee IDIF <br /> Grout Inspection By SPECIAL Well Permit <br /> Pum Inspection By ate WAIVER Received <br /> Sell Boring In on By Date Constructed Well Depth ft <br /> COMM S <br /> E C Received Amount PennlU Lnvo(c*f WNIIDO <br /> Codes Info RemBfed �ta Service <br /> t <br /> 14310 0 23`46 16R2 IV % 3 a u1 oa3! <br /> EHU 43M WELL PUMP PERMIT <br /> 8,040E <br />