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6 Cc cl S-1 &VELL / PUMP PERMIT ��///_> <br /> SAN JO'AQUIN COUNTY ENVIRONMENTAL HEALTH DE ENT 304 E WEBER A�a FLVS ST TQ�Y 9 k (209)468-3420 <br /> c""`a� ".r �..�NN .a.'' <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIIt� 1 NRli7l T1iATE ISSUED <br /> p/ / y�.- ,y� p rn <br /> JOB ADDRESS -/ ✓ r v�` r �/ ���/ \ CITY/ZIP �h-�T6c/s/ GA (532 y <br /> }� /_^n °v <br /> CROSS STREET ��-�, d/�e�/►�� )APN �0 I o11J/��1�(j'��-�-� PARCEL SIZE LAND USE APPLICATION# �J �/ p <br /> OWNER NAME /'S(J/14/ <br /> C 169k��.V,y�1/WW& �/�^-�� �G� PHONE Z047— <br /> F,&:? - TZ?G> <br /> OWNER ADDRESS 1✓ N ' 6 7Et 7 CITY/STATE/ZIP S mr ll/[/�'//of �/�,' 5W <br /> CONTRACTOR f ��y /p yAA/ / v `/�/� QCI I T : 8AS PHONE 7 OQ�`' ` `n <br /> CONTRACTOR ADDRESS �1AC2 If/A �L� VL 5 � /DQII✓1= CITY/STATE/ZIP h//�-/�dQ&A) !J CA <br /> SUBCONTRACTOR 8/j `-y/"Sjk4C7ZaA1/ LP PHONE qts' -R�o 7 <br /> SUBCONTRACTOR ADDRESS 1'34,0 PKI VE CITY/STATE/ZIP b%/iA W 1,V &V- / /Y It 71G 15 *-u <br /> LICENSE XC-57 ❑C 61 ❑D-09 ❑Other NUMBER 3'? EXPIRATION DATE 02-007 <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y D A/Township -I= Range See w �!/�- " <br /> INTENDED USE ❑Domestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization <br /> ❑Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone��Number <br /> TYPE OF WORK XNew Well ❑Replacement Well ❑Well Alteration/Modification �Other�A*- Ola e <br /> ( #of borings #of borings <br /> 13 Monitoring Well s) #of wells ❑Soil Boring(s) ❑Geotechnical <br /> ❑Out-Of-Service Well Z ft* ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> ❑New Pum ❑Pump Replacement ❑Pump Repair <br /> WELL CONSTRUCTION � I SHZE-T <br /> Drilling Method 13Mud Rotaryy'�Air Rotary 'l 1uger ❑Cable Tool ❑Push Point ❑Other <br /> Proposed Well Depth A~ft Excavation 15 1 1 in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter <br /> ❑Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter 3 in Thickness/Gauge/ASTM Sched 00 ❑Steel , .Elastic ❑Stainless Steel ❑Other <br /> Grout Seal Depth 1447e(C� ft ❑Neat Cement(94 lb bag/5-10 gal water) ❑Sand Cement sack mix/7 gal water <br /> RBentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted <br /> Grout Placement Method ❑Pumped WFree Fall ❑Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑ Other <br /> ❑Concrete Pedestal Dimensions:Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe <br /> PUMP ❑Submersible ❑Turbine ❑Other HP Pump Set ft Standing Water Level ft <br /> I HEREBY CERTIFY THAT 1 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 /> � NIMUM OUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS yy � <br /> SIGNED TITLE �&(NCf DATE &1&124(..C.� <br /> J h <br /> r <br /> N JO,kQ IN N <br /> DEPARTMENT USE ONLY <br /> Application Accepted B QA o. Date Area Employee ID# 154.1�> <br /> Grout Inspection By Date :7 / t�5- ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received heck_# Amount ate Permit/ Invoice# Well ID# <br /> Codes Info B s Remitted I A Service Re u # <br /> EHD 43-02-006 (�Jr �1� (Vj) WELL PUMP PERMIT <br /> 1/27/2005 <br />