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t. f WELL/PUMP PERMIT SAN JOAQUIN COUNTY ENVIRON.NLN-IAL HEALTH DEPARTMENT 304 E W'FBER AVE 3"FL-STOCIc'fON CA 95202 -(209)468-3420 NON-REFUNDABLE PERMIT CALL.(2419)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOA ADDRESS t-- _ f CITY ILIP.- t 1 > X93 3 CROSS STRr'.FT �� PARCFI.SILE LAND USF.APPLICAl10N� rx„ OWNER NAME tAPN PHONE-2LYI�,OWNER ADDRESS - I� CITY/STAT£ILIP ` /� � CONTRA(-rOR J11_LPIIONE CONTRACTOR ADDRESS / ) L� r r CITYi SIAT E/ZIP SLBCONTRACTOR PHONE 7J/ SLfCON'I stAc ciR ADDRESS C / ST /ZIP / LicENSE C-$7 OC-61 OD-04 ❑Other NUMBERL EXPIRATION DATE /� GEOGRAPH(CAI.I VFORMATION: Coordinates X Y Township Range Section v} INTENDED USE Domestic Private ❑Irrigation'AgriculLurel ❑Industrial ❑Watcr Qualay Monitoring ❑Soil Sampling/Characterintion ❑Public Water System It Mfgi lrum UWner. ' FSr -m s— un I Name cr vn�h�+m�ror TYPE OE WORK 0 New Well ❑Replacement Well ❑Wcll AlterationAMod:hcatior. ❑Other ❑Monimrng W'cll(s) b of wills O Sal Hnring(s) sorhorinas ❑Gcprcchnicil so(borinas ❑Out-Of-Service Well OOut-Of-Service Well Renewal 11 Cross-Connection Repair El New Pump ❑Pump Replacement APump Repair WELL CONSTRUCTION Drilling Method ❑Mod Rotary ❑Air Rotary ❑Auge- ❑Cable Tool ❑Push Point ❑Other_ Proposed Well Ocpth_. R Excavation__ in diameter ❑Open Bottom O Gravel Pack/Gravel Siix - in diameter ❑Conductor Casing in diameter / Conductor Casing Depth R Well Casing Diameter in Thickness'OaugeASTM Sched - .. ❑Sicd ❑Piasuc ❑Stainless Steel ❑Other Grout Seal Depth R ❑Neat Cement(94/L bag/5-/0 gut wurer) U.Sand Cement ____ ruck oris/7 gal water ❑Dentunite(20%solids) ❑Manufacturer Spit%solids Name_ ❑Specs on File O Specs Submitted Grout Placement Method ❑Piimped O Free Fall ❑Other_ ❑Retn_rdant/Accelerator(name) PEDISUAL Installed By ❑Driller ❑Pump Contmcior 0 Other -y ❑Concrete Pedestal Dimensions:Width R Lcngth--ft Thick in O Christy Box ❑Stove Pipe LL—MP Submersible ❑Turhirc ❑Other HP Pump SeI._ ft Standing Water Lcvcl R I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION .AND THAT THE WORK WILL BE DONE 1N ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND Rt:CULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND ACTIVE WITH'rHE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. � MI it 1 M 24 HOUR ADVANCE NOME REQI.IRkAl M'OR INSPECTIONS �rl � SIGNED TIILE t� rC.. DATE I I JE�TA D PA TM1IENT USE ONLY' Application Accepted B- - Date v Arca rmploy!c iD4 (trout Inspection By _ Date—._ ❑ SPECIAL Well Permit Pump lnspectior.By Date 5//'6,f/ 171 WAIVER Received Constructed Welll/ pth ' / �It —T COMMENTS PE SC RecclYed hccI0 Amount T -PermlTl',� Codes Info R .as Remitted Date Servlra Request k ,, lnvoice M Well IDK • Fnn I t-a:.orr. WELI.YUMY Yt.1t511T ::'.]::005