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WELUP�UMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEAL TI/DEPARTMENT 1866 EAST HAZEL TON AVENUE-STOCK TON CA 95205-(209)466-3420 <br /> NON-REFUNDABLE PERMIT SALL 209 953-7697 FOR INSPECTIONS E PIR§S 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS -� �N� / -__ CITY/ZIP lr <br /> D <br /> CROSS STREET /NLN j/� /. APN Dq-/A�I -d PARCEL SQE C1 IANU USE APPLICATION <br /> OWNER NAME �X^L (50A&S i PHONE ahq� in.�/��/�? <br /> OWNER ADDRESS J CITY/sTATE/ZlP- W . 6A <br /> CONTRACTOR x� ' 33$4 y_...7 <br /> CONTRACTOR ADDRESS 04 Pdald 17P P CRY/STATEZP <br /> SUBCONTRACTOR 3S _ PHONE,3 Z — :?I21.2-_—_.-_ <br /> SUBCONTRACTOR ADDRESS -_ _ Crry/ST.A�TEEMP <br /> LICENSE )<57 C-61 D-09 Other NUMBER 3 7 2 JO" EXPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section_._-, <br /> INTENDED USE mesticJPrivate Irrigation/Agricultural Industrial Water Quality Monitoring Soil Sampling/Characterization <br /> Public Water System <br /> It different from Owner: Water System Name —--Contact Name or Phone Nurritier <br /> TYPE OF WORK 7l1ew Well }replacement Well Well Alteration/Modification Other <br /> Monitoring Well(s) R of wells Soil Boring(s) s of bomps Geotechnical If of born ps <br /> Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair <br /> New Pump Pump Replacement Pump Repair Raise Well Casing <br /> WELL CONSTRUC��T/ION <br /> Drilling MethoMud Rotary Air Rotary Auger Cable Tool Push Point Other <br /> Proposed Well Depth Do it Excavation 1 L In diameter Open Bottom Gravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth_ It <br /> Well Casing Diameter 4!!�' in Thlckness/Gauge/ASTM Schad-7 ,; Steel >Pastic Stainless Steel Other <br /> Grout Seal Depth�aO R Neat Cement(94 Ib bary5-10 gal water) and Cement �y: sack miV7 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method Pumped Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller Pump Contractor Other <br /> Concrete Pedestal Dimensions:Width it Length It Thick=in Christy Box Stove Pipe <br /> PUMP ubmersible Turbine Other HP Pump Set M Standing Water Level ft <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQ'UIN COUNTY ORLMNANCES. STATE 'LAWS, A ^L'LES AND PEC;CLAT!OHS. I ALSO CEFTIFY TI IAT ','.Y <br /> „ °FLED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM INCOMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED ``,,,L _ y TITLEL)VL4.•��- DATE <br /> 4 <br /> S Lit <br /> Olt <br /> REI <br /> -14 IL 3A III "11L <br /> li J <br /> EhAHON E T <br /> UE AHTMENT U E ONLY <br /> ,_/ <br /> Application Accepted By -_ Date �- Area Employee ID#.h&A* <br /> Grout Inspection By a Data I U SPECIAL Well Permit <br /> Pump Inspection By Date FT WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth._ it <br /> COMMENTS <br /> PE SC Received Cheek!/ Amount Date Permit/ Invoice If Well IDR <br /> Codes Info B Remitted Service Reguest f1 _ <br /> 311- ---- - - � � - ----- - - <br /> L WELL/PUMP PERMIT <br />