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WELL/PUMP PERMIT <br /> SAN JOAQUN COUNTY EWROMIENTAL HEALTH DEPARTMENT 600 EASTMAIN STREET-STOCxroNCA 95202 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> Joe ADDRESS / ?yJr � Sos .�o4 e./ C"rZi, <br /> CROSS STREET U0'1 �. .-4�T APN PARCEL SIZE LAND USE APPLICATION k <br /> OWNER NAME ��(,/L��"/'� ' > ��L �S6 4 e PHONE 12-01) <br /> OWNERADDRESS 1 (�/ VOA SDS�fJ� �ORa/ CITYfSTATFJZP T-rc,� Z <br /> CONTRACTOR bye"rf- LoC..g4S'�h rEarr�-�'•'�.. D3A BPRf ley �ec��t10NE ' ( �CILI35 —Zfi <br /> � •�, ' n Gy g <br /> CONTRACTOR ADDRESS 64 <br /> _ I ,L • B�X ISI CITYISTATEMP r 1 Cr /5 7 U <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITYISTATEJLP -�7.,_ __ <br /> LICENSE C-57 C-61 D-09 &h. Z 1 GAG NUMBER 73 9�F EXPIRATION DATE O$/21�0`7 <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section <br /> INTENDED USE domes iclPrivate Irrigation/Agricultural Industrial Water Quality Monitoring Soil Sampling/Characterization <br /> Public Water System <br /> It Nlrerant Yom Omer. Wte,SyCern N— Contho Name or Phone um r <br /> TYPE OF WORK_ New Well Replacement Well Wel Alteration/Modification Other <br /> Monitoring Wall(s) #of wells Soil Boring(S) sorboIln" Geotechnical Rol borings <br /> Out-Of-Service Well Out-Of-Service Wei Renewal Cross-Connection Repair <br /> New Purnp PumpReplacement Pump Repair <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary Air Rotary Auger Cable Tool Push Point Other <br /> Praposed Well Depth If Excavation In diameter Open Bottom Gravel Pack/Gravel Size in diameter <br /> Conductor Casing In diameter I Conductor Casing Depth ft <br /> Well Casing Diameter_In Thickness/GaugeIASTM Schad Steel Plastic Stainless Steel Other <br /> Grout Seal Depth ft Neat Cement(941b bagib 10 gat wafer) Sand Cement sack rnixl7 gal water <br /> Bentoniia(20%solids) Other <br /> Grout Placement Method Pumped Free Fal Other Retardant f Accelerator(name) <br /> PEDESTAL Installed By Driller Pump Contractor Other <br /> Concrete Pedestal DtmensiorI Width R Length _ ft Thidc.__ In Christy Box Stove Pipe <br /> PUMP plSubmerslble Turbine Other HIP eC� ft Standing Water Level <br /> I 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 /> MIN UM 24 HOUR ADVANCE NOTICE REQUIRED_FOR/INSPECTIONS <br /> SIGNED ITLE / `� —je I`�-�.�'Ll�[.- `� DATE/� /y <br /> D <br /> w <br /> I <br /> I <br /> A MENT U E O LY /(,�///�� <br /> Application Accepte Date Area Emplayee IDk //f <br /> Grout Inspection By ate SPECIAL Well Permit <br /> Pump Inspection By ate WAIVER Received <br /> Soil Boring in ion By - Date Constructed Wall Depth ft <br /> COMMENTS <br /> PESC Received eckb1 I Amount Permit/Codes Info By I Remitted Date Service Request k Invoice k Well IDk — <br /> EHJ e'eve WE-LJ'UMP FERVIT <br /> i25N7 <br />