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' WELLIPUMP PERMIT SAN JOAQUIN Colum Ewimm dENTAL HEALTH DEPARTMENT 1868 EAST HA2ELTorf AvEHue-STocKmN CA 95205-(209)4683420 NON-REFUNDABLE PERMIT LVL LL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED Jog ADDR63 J/ W�C'/i L/L>lrT� �� Cn,'.' "125 ��cl4 �J 3� 7 m CRoss STREET r N T r �C. APN )A I / PARra Sty I LAND USE APPuunoN omER NAME ?-rf`V A.c-K-er HONE Y P (DINNER ADDRESS :5*4,.p- CITYISTAIE/ZIP J / CONTRACTOR NatR_ Ra �� CONTRACTOR ADDRESS �O• \�� 0 � GTY/STATElLP Cl'4'C� SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS CTTYISTATEIZIP LICENSE E C-57 LyE11 D D-09 E Other NLV ER LCS� ExPIRAnONDATE DOMESTIC WELL SAMPLING:u General MineratUColifonn Bacteria(4391) Dibromochtoropropane(4392)❑Arsenic(4393) INTE"Qee Use G Irtigation/Agriadtural a Industrial C Water Q—hty Monitonng a sod sampnng/CharaCtenZaDon 'u Public Water System - Ir ddl—N Dom DWner. WdtC System Name Cordal Nanta or Pb—t Number TYPE OF WORN E New Wen ❑Replacement Wei D Weil AfteratiMModi6plion ❑Other ! Monitoring Well(s) Y of wells `=Sal Boring(s) sal rorty. ❑Geotechnical a of b..g; Out-OfService Well OUEOf-Service Wen Renewal O Cross-Connection Repair New Pum u Replacement D Pump Repair ❑Raise Well Casing WE LCoNsTRucnoN Drilling Method G Mud Rotary �L,Air Rotary L'Auger F.Cable Tool �]Push Point _ Other Proposed Well Depth ft Excavation in diameter Open Bottom ❑Gravel Pack/Gravel Size in diameter L3 Conductor Casing In diameter / Conductor Casing Depth It Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑Steel ❑Plastic 0 Stainless Steel tl Other Grout Seal Depth ft ❑Neat Cement(94 lb bag/5-10 gal water) ❑Sand Cement sack mix/7 gal Water Bentonite(20%solids) ❑Other Grout Placement Method E�Pumped ❑Free Fan C-Other ❑Retardant/Accelerator(name) PEDESTAL Installed By ❑Dnl" D Pump Contractor ❑ Other ❑Concrete Pedestal 0Dimenslons:Width ft Length ft Thick in G Christy Box ❑Stove Pipe Punm uhmerwbleC Turbine C Other HP Pump Set ft Standing Water Level ft 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS INIMIUM NO' ADVANCE NOTICE REQUIRED FJO�R INSPECTIONS-PL�EIASE CALL(209)953--7697 SIGNED 22-x- t r•L� TrtLE I..' • 't�.�3 ,� DATER I FFT-T-1 Q, Ilk cFi1FN�, UN Fp 0,2 — -- � I - MF,yr EPARTMENT USE ONLY t� ZJZJ Area " C) Employee IDR Application Accepted By Date Grout Inspection By Date ❑ SPECIAL Well Permit Pump Inspection By fCI.,nki t Ta flat:... s i Date U WAIVER Received Soil Boning Inspection By Dale Constructed Well Depth ft COMMEN TS _ PE SC Received Check#/ Amount Date Permit/ Invoice# WellIDk Codes Info B Cash Remitted S ivice Requests ?Ci EHD 4306 lowed 4/14/16 WELL/PUMP PERMIT