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DEPARTMENT USE ONLY <br />Date_1411 /ô '''? Area Employee ID#34, .1f it <br />Date jp (IA. CP:_l___ 0 SPECIAL Well Permit <br />0 WANER Received <br />Application Accepted By <br />Grout Inspection By <br /> <br />Pump Inspection By Date <br /> <br />Constructed Well Depth ft <br />COMMENTS <br />PE <br />Codes <br />SC <br />Info <br />Received <br />BY <br />Check#/ <br />Cash <br />Amount <br />Remitted Date Permit/ <br />Service Request /f Invoice # Well IDif <br />O 1 I., '-fl-- /.2.4tC, $ 1 GI (.111 -7 .6-10 q--S- <br />EHD43-02-065 web <br /> WELL PUMP MOUT <br />1127/2005 <br />WELL / PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 E. Main Street - STO.o ON CA 95202 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT CALL (209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />ida2,___VSL010._) °E.-) c.SLibcik4elfir_g_5,2e23 <br />CROSS STREET _1\1‘3_2:ial.) APN <br />OWNER NAME thild,&rafs____fra) <br />JOB ADDRESS <br />PHONE <br />OWNER ADDRESS go-2_ tio ,_ tAy?, ev--- Nver, ve_, cirvistma,, (S40c_,k_{_ny-, , , ct E203 <br />CONTRACTOR PHON --(1,0.i 14 94 -3'ili-e) a laeAr, Siet.4€ P.Avit'oornerrimii loc , <br />CoNTRAcTott ADDRESS j5C)S I La (f- sAdl...,t)ett 941. rio.2..c.srATFizip I ir 6 0 6 <br />SUBCONTRACTOR -S 1 ',Axil I <br />SUBCONTRACTOR ADDRESS 2-2-D 1\i <br />LICENSE RTC-57 DC-6t 0 0-09 0 Other NUMBER e-D-13S4+ EXPIRATION DA <br />PARCEL SIZE LAND USE APPLICATION 0 <br />CITY/STATE/ZIP <br />532-2i4-2,q- <br />q <br />GEOGRAPHICAL INFORMATION: Coordinates X <br />INTENDED USE 0 Domestic/Private 0 Irrigation/Agricultural 0 Industrial 0 Water Quality Monitoring Sampling/Characterization <br />0 Public Water System <br />If different from Owner: <br />Township Range Section <br />Water System Name Contact Name or Phone Number <br />TYPE OF WORK 0 New Weil 0 Replacement Well 0 Well Alteration/Modification 0 Other <br />0 Monitoring Well(s) 9 of wells ,Soil Boring(s) of borings 0 Geotechnical O af borinp <br />0 Out-Of-Service Well 0 Out-Of-Service Well Renewal 0 Cross-Connection Repair <br />10 New Pump 0 Puma Replacement 0 Pump Repair <br />Writ CONSTRUCTION <br />Drilling Method <br />Proposed Well <br />Well Casing <br />Grout Seal <br />Depth s <br />1:1 Cable Tool 0 Mud Roir / I , 0 Air Rotary 0 Auger n <br />Diameter _Yfin Thickness/Gauge/ASTM Sched 0 Steel <br />0 Conductor Casing in diameter I Conductor Casing Depth <br />Depth ft 0 Neat Cement (94Th bag / 5-10 gal water) <br />Excavation i 5" ,' ft 5 diameter 0 Open Bottom 0 Gravel Pock! Gravel Size in diameter <br />*push Point <br />0 Plastic 0 Stainless Steel Aitf.Dther POLi <br />0 Sand Cement sack mix 17 gal water <br />ft <br />0 Specs on File 0 Specs Submitted 0 Bentonite (20% solids) 0 Manufacturer Spec % solids % Name <br />Grout Placement Method 0 Pumped tit:Free Fall 0 Other 0 Retardant / Accelerator (name) <br />0 Other Installed By 0 Driller 0 Pump Contractor PEDESTAL 0 Christy Box 0 Stove Pipe ft Length ft Thick 0 Concrete Pedestal Dimensions: Width <br />ft Pump Set ft Standing Water Level HP 0 Submersible 0 Turbine 0 Other EMU <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 />IZIGNED <br />24 HOUR ADVANCE NOTICE RE5ATIRED kONNSPECTIONS <br /> <br />Tin; 4-111-Ctielc-F oSlicADATE 64r(67 <br /> <br />td <br /> <br />9 <br /> <br />007 <br />!i- <br /> <br />EN <br /> <br />S — <br />\ <br /> <br />/a VIUP <br /> <br />Ill <br />