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WELL I PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT — 304 E WEBER AVE 3-FL-SToacroN CA 95202 -(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209/9953-7697 FOR INSPECTIONS EXPIRES i YEAR FROM DATE ISSUED <br /> JOB ADDRESS �� - CITY/ZIP C.0 LO9014*1 R0 01 <br /> `u 7 <br /> CR09S STREET APN PARCEL SIZE LAND USE APPLICATION# <br /> OWNER NAME PHONEn,.I',p}� <br /> OWNER ADDRESS O ` L <br /> CiTY/STATFJZIP <br /> CONTRACTOR A&4 ..PHONE Tr4,e <br /> CONTRACTOR ADDRESS 01 CMISTATFJZIP <br /> SUBCONTRACTOR PHONE <br /> SUDCONTMZ.,A/DpRC$3 CITY/STATE/ZIP '7 <br /> LICENSE Yi:57 ❑C-61 ❑D-09 13 other NI:MBER E%PIRATION DATE /—3/~ia <br /> CEO GRAPRICALINFORMATION: Coordinates IYTownship Range Sectlon_ <br /> INTENDED USE ❑Domestic/Private rrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization <br /> ❑Public Water System <br /> IfdiRerau fmmt)wne: nm,yztemTJa e-_-- - -_ - C..c .arm«Phooe N..ber <br /> TVPEOF Woitx ❑New Well ❑Replacement Well ❑Well Alteration/Modification ❑Other <br /> ❑Monitoring Wells) k of wells ❑Soil Boring(s) a of boinW ❑Geotechnical a or borings <br /> ❑Out-Of-Service Well Well Renewal ❑Cross-Connection Repair <br /> ❑New Pump ❑Pump Replacement mR <br /> WELL CONSTRUCTION <br /> Drilling Method ❑Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Other <br /> Proposed Well Depth ft Excav in diameter„ '❑Open Bottom rave Pack/Grave in diameter <br /> ❑Conductor Casing in diameter o uctorCasing D fl <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Sehed Steel ❑Plastic ❑Stainless Steel ❑Other <br /> Grout Seal Depth ft ❑Neat C bag/5-10 gal water) rent sack mix/7 gal water <br /> ❑Bentonite(20%solids) tufacturer Spec%solids % Name Specs on File ❑Specs Submitted <br /> Grout Placement Metho ped ❑Free Fall O Other ❑Retardant/Accelerator(name) <br /> PEDEsrAL Installed By ❑Driller ❑Pump Contractor ❑ Other <br /> ❑Concrete Pedestal Dimensions:Width ft Length It Thick in ❑Christy Box ❑Stove Pipe I <br /> PUMP ❑Submersible Ourbine ❑OtherHP Pump Set ft Standing Water Level It <br /> I 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 CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> s <br /> MINIMI 4 HO R ADVANCE NOTICE RMU1RE�7D/+F'OR INSPECTIONS <br /> SIGNED t TITLE iV/ • DATF, <br /> V <br /> L) <br /> - e — - -- - - -- -- - T - <br /> :DE F AR MENT USE OILY <br /> �9 <br /> Application Accepted Date v 2 0 Area Employee IDN- <br /> =p <br /> Grout lnspect� n By Date ❑ SPECIAL Well Permit f <br /> Pumpinspection By Date //��� 13 WAIVER Received ' <br /> Constructed Well Depth D <br /> COMMENTS <br /> PE SC Received C ecW Amount Date Permit/ Invoice# Well ID# <br /> Cod Into B Cash Remitted Service Request# <br /> Ath IF3(Ilk <br /> DID 0-024)06 - WELL PUMP PERMIT <br /> Ir2V2005 <br />