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WELL/PUMP PERMIT <br /> N RONMENTAL HE DEPARTMENT 600E CANNED <br /> tw% MAINS ET CA 95202-(20V 468-3420 <br /> ON U MIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> Joe ADDRESS -7 C J tyrv21P � Lf <br /> p4. has d PDwpeiy� <br /> QI 11{ CATIOVIRECTOR m <br /> PHONE Donna Heran, ISS <br /> ERN <br /> L ? s J INATORS <br /> D. , 2�v- ' Z_Ij:c@a bClello REHS <br /> PHONE <br /> rr EH_S, RDI <br /> 70 ADDRESS CfTY!$7ATE/ZM <br /> e i e: www.sigov.org/ehd PHONE Linda Turkatte, 151�s <br /> q / CTOR Phone. 209)468-3420 \ <br /> SUBCONTRACTOR ADDRESS 3�'TM/STATE/ZIP l ,^ <br /> LICENSE C-57 ❑C-61 ❑D-09 ❑Other NUMBER v EXPIRATION DATE O�J O/ <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range SeCtlOn <br /> INTENDED USE ❑Domestic/Private ❑Irrlgation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterizaton <br /> 'S( ublicWater System <br /> 'ttf difremrt from 0wnsr Water SySte. ame Co4act Name or one um <br /> TrPE OF WORK Cl New Well Replacement Well ❑Well Alteration/Modification ❑Other <br /> ❑Monitoring Well(s) #of wells ❑Soil Boring(s) 0 of Wrirgs ❑Geotechnicat #of borings <br /> ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal O Cross-Connection Repair V <br /> ❑New Pump ❑Pump Replacement ❑Pump Repair O Raise Well Casing <br /> WELL CONSTRUCTION"" <br /> Drilling MethodXMud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point a Other <br /> Proposed Well Depth O Q it Excavation 1-7— in diameter EI Open Bottom p Gravel Pack/Gravel Size in diameter <br /> ❑Conductor Casing In diameter / Conductor Casing Depth ft <br /> Well Casing Diameter 0 In Thlckness/Gauge/ASTM SchedI;,�J59 ❑Steel Plastic ❑Stainless Steel ❑Other <br /> Grout Seal Depth 1W ft ❑Neat Cement(941b bag(5-10 gal water) ❑Sand Cement 10,3 sack mix/7 gal water <br /> ❑Bentonite(20%solids) ❑Other (y�' <br /> Grout Placement Method umped ❑ Free Fall ❑Other _ O Retardant/Accelerator(name) {}� <br /> PEDESTAL Installed By O Driller >0ump Contractor ❑ Other `I <br /> ❑Concrete Pedestal Dimensions:Width ft Length ftThi k in ❑Christy Box n Stove Pipe <br /> PUMP ❑Submersible❑Turbine ❑Other HP Pump Set ft Standing Water Level it <br /> I HEREBY CERTIFY THAT I RAVE 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 AD�OTICE REQUIRED FORINSPECTIONS-PLEASE CALL(209)953.7697 <br /> SIGNED V t 1. Y r'l TM-E \1 v.i <br /> v- • <br /> 3'f <br /> It <br /> Ma <br /> }1' 35rIt <br /> 4;' G <br /> l 3 1 <br /> e'l•s t <br /> J <br /> Tit <br /> T� <br /> HE 411 Trzp <br /> DEP RTMENT USE ONLY <br /> Application Accepted.By l� ate Employee ID#�� <br /> Grout'inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE Sc Received Amount Date PerrnlU Invoice# Well Codes Info B Cash Remitted Service Request# <br /> EHD 43-09 WELL/PUMP PERMIT <br /> 626109 <br />