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WELL/ PUMP PERMIT SCA10% ,NAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3'"FL-STOCKY A 95202 -(209)468-3420 NON-REFUNDABLE PERMIT CALL,(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS I r OL�IJ-S,,-4 c,14 CITY/ZIP jDwCGY _ CROSS STREET L�M�e�,,F,,S�'�_ APN '' -�3 PARCEL SIZE�- b LAND USE APPLICATION N OWNER NAME R/yV( Ole,pG-x-'Oe7 - PHONE 2r3i;—,g Tl� 17ri= OWNER ADDRESS — JT CITY/STATE/ZIP CONTRACTOR �v t` PHONE CONTRACTOR ADDRESS AeWf CITYISTATEIZIP ) - SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS_ CITYISTATE/ZIP LICENSE ❑C-57 ❑Cfil ❑D-09 >i!Nher C d DZ( NUMBER _ E%PIRATION DATE GEOGRAPHICAL INFORMATION: Coordinates X Y Township Rnnii Section INTENDED USE O DomesticlPrivale ❑Irrigation/Agriculmral �%123dustrial ❑Water Quality Monitoring G Soil Sampling/Characterization ❑Public Water System Ifilff est from .. alar ysum ams CorwtNar jr ne u r TYPE OP WORx ❑New Well ❑Replacement Well ❑Well Alteration/Modification ❑Test Hole ❑ilther ❑Monitoring Well(s) N of wells ❑Soil Boring(s) s°rb°nngs J Geotechnical s Meon°W ❑Well Destruction Q_M #2, ❑Out-0f-Service Well ❑Out-Of-Service Well Renewal ❑New Pump _4R1ump R lacement ❑Pump Repair C3 Cross-Connection Re air WELL CONSTRUCTION Drilling Method ❑Mud Rotary ❑Air Rotary ❑Auger Q Cable Tool ❑Push Poim ❑Other 1 Proposed Well Depth 11 Excavation in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter .--� ❑Conductor Casing in dianxter / Conductor Casing Depth 11 Well Casing Diameter_In Thickness/Gauge/ASTM Sched_ ❑Steel ❑Plastic ❑Stainless Steel ❑Other Q Grout Sul Depth ft ❑Near Cement(941h hug/3-10gal water) O Sand Cement nock mix/7 gal water ❑Bentonite(20%solids) Q Manufacturer Sptc%solids % Name _ ❑Specs on Filc ❑Spas Submitted Grout Placement Method ❑Pumped ❑Free Fall ❑Other_ ❑Rdardarit/Accelerator(name) PEDESTAL Installed.BY ❑Driller 17 Pump Contractor ❑Chher ❑Concrete Pedestal Dimensions: Width R Length R Thick in ❑Christy Boa ❑Stave Pipe n PUMP bmersible ❑Turbine ❑Other "P= 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. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS y CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL Rl WORKERS COMPENSATION LAWS. 24 HOUR ADVANCE NOTIC RFjU IRED FOR INSPECTIONS L_ SIGNED TITLE �� DATE O✓ TT r C OUF ±H±H± S E n T 0 rpEPARTME NT USE ONLY Q Application Accepted By l� Date U s , Area Employee IDN ✓�pt7O Grout Inspection By Date ❑ SPECIAL Well Permit Pump lnspaGon By Date ❑ WAIVER Received Destruction Inspccuon By Datc Constructed Well Depth It COMMENTS PE I SC ReceivedChec Amount Permit/Codes Info B ash Remitted Date Service Request N Invoice N Welt IQtl �13.d1 nso1 q;,Z ,o.ot� jL oS OD ( 53