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WELL/PUMP PERMIT ,"14 <br /> S A NJOAOLIIN Cnt,NTY ENVIRONMENT At-HEAL III Df-PAnTMENT I EAST HA7EI ToN Avrriur-STor)(TON CA 95205 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL N9).9,53-7697 FORINSPECTIONSEXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB Ar)DRFSI-; Z6 0 CITY01, —2-1-761 6A �5 Z*O > <br /> APN PARCEL SIZE LAND USE APPLICATION ft <br /> CROSS STREET M <br /> In <br /> OWNER NAME PHONE 4`io�l <br /> iOwN-R ADDRESS CITY/STATE/ZIP <br /> CON!RACTOR A-A _'0 PHONE"'Z __31 <br /> CONTRACTOR ADDRESS CFTYISTATE/ZIP <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATEIZIP- <br /> - <br /> LICENSE�-5D-09 Other LIMBER7 C-61 N EXPIRATIONDATE <br /> GEor.RAPHICAL INFORMATION: Coordinates X y Township Range— Section_ <br /> INTENDED USE _<Domestic./Private Irrigation/Agricultural Industrial Water Quality Monitoring Soil Sampling/Characterization <br /> Public Water SystemII -7?!2_n1ac1W9_n_ioor_PTione umer <br /> 11 diftereni from Owner: <br /> TYPE OF WORK ><qew Well Replacement Well Well Altoration/Modification Other <br /> Monitoring WeII(s)_____ __ 9 of wells Soil Boring(s).— #of borings Geotechnical__0 of borings <br /> Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair <br /> '--ci Pump Pump Replacement Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drill ng Methodw<ZMud Rotary Air Rotary Au Cable Tool Push Point Other <br /> Proposed Well Depth-.-2)%_a_-3 it Excavation 7ral— __ in diameter Open Bottom 11<6ravel Pack/Gravel Size___ in diameter <br /> Conduc q asing in diameter / Conductor Casing Depth It <br /> Well Casing Diameter in Thickness/Gauge/ASTM Schad Steel ----61astic Staint ss Steel Other- <br /> ------ <br /> GroutSeal Depth it Neat Cement (94 lb bag/5-f0 gal water) and Cement- sack mixf7 gal water <br /> Bentonite(20%solids) Other <br /> LGrout Placement Method_je�umped Free Fall Other Retardant/Accelerator(name) <br /> [PEDESTAL Installed By 4<Lriller Pump Contractor Other <br /> Concrete Pedestal Dimensions:Wi(Illi It Length it Thick in Christy Box Stove Pipe <br /> FELL,P-A L, pg6ubmersible Turbine Otho, Fill <br /> I— Pump Set It Standing Water Level ft <br /> 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 CALIrnRNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MINIMUM 24 HO R ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br /> SIGN170jLAJ/­t-b-I—_ <br /> Tiit i DATE <br /> jg <br /> T 'I <br /> r --- <br /> WL <br /> F <br /> r% <br /> U_A Pill, <br /> 2 <br /> ai <br /> 14T <br /> 1'6 1 1 <br /> DEPARTMENT USE ONLY <br /> Application Accepted B ^Jq!�OM_4, Date Area Emplovee ID# tArz-VA-T, <br /> Grout Inspectio LSC_-- Date SPE CIAL Well Perinit <br /> Pump Inspection B Date WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COtAMENTS ALA,--.� L-�Zf fuad IaA,;, A w41 <br /> PE SC Received e c k ItT, Amount Permit/ <br /> Date Invoice It Well ID# <br /> Codes Into By Remitted_—-- Service Re_qoast# <br /> 4-lib IL 190 0 0 7o(+s <br /> e <br /> 41%0 050 2AW �3 ci 0 b 4.6 I <br /> EHD 0.06 WELL/PUMP PEFk <br /> 4r"T2 <br /> w A�_ <br />