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&VELL / PUMP PERMIT • <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPAItTMEN� 304 E WEBER AVE31DCO(DCP95202Y- O9)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS O p /U p wl �L 7 pL G ffb CITY/ZIP t//V iD , 95-2S6 9 <br /> v <br /> CROSS STREET APN PARCEL SIZE LAND USE APPLICATION# <br /> PHONE NAME LOOOEY o <br /> OWNER ADDRESS /910k. L ©ArCTY/STATE/ZIP �Vt�`(�/0-A[J~ iap�s �??.5-26Yl©Z�dSY <br /> CONTRACTOR (A)O0rb k/ [ J !/ eoPHONE [S-2` 2-Z� 71S <br /> CONTRACTOR ADDRESSI-z,1/'fXJ CITY/STATE/ZIP Lgmos �r /l <br /> SUBCONTRACTOR LF15 <br /> / T&Atl"18' PHONE <br /> n <br /> SUBCONTRACTOR ADDRESS tJ H r fzj !-ffe' s z� CITY/STATE/ZIP nnf X - CA �53 <br /> LICENSE ❑C-57 ❑C-61 ❑D-09 Other NUMBER 0 EXPIRATION DATE 2-7--©k <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <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 ❑New Well ❑Repl ement Well ❑Well Alteration/Modification Cher <br /> onitor ng Well(,) #of wells ❑Soil Borings) #of borings ❑Geotechnical of borings <br /> ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> ❑New Pump ❑Pump Replacement ❑Pump Repair <br /> WELL CONSTRUCTION <br /> Drilling Method ❑Mud Rotary [3 Air Rotary Iger 13 Cable Tool ❑Push Point ❑Other <br /> Proposed Well Depthlft Excavation in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter <br /> ❑Cor�et�to���g in diameter / Conductor Casing Depth ft <br /> Well Casing Dia er to Thickness/Gauge/ASTM Sched ❑Steel ❑Plastic 13 Stainless Steel ❑Other <br /> Grout Seal Depth ft ❑Neat Cement(94 lb bag/5-10 gal water) ❑Sand Cement sack mix/7 gal water <br /> )0: »tonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted <br /> Grout Placement Method ❑Pumped >: t=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 R <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 /> /� MI UM 24 HOUR ADVANCE NOTICE EQUIRED FOR INSPECTIONS Q /' <br /> SIGNEE�%c�%J�=i�l�irwLl 122M/t1 TITLE ��17` DATE <br /> S N p <br /> E VI ONMENTAL <br /> ATM N <br /> DEPAR MENT USE ONLY <br /> Application Ac ted Date Area Employee ID# <br /> Grout Inspection By ate fie,/y D(� ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Constructed Well Dept It <br /> COMMENTS <br /> PE SC Receivedheck#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info By Cash Remitted Service Request# <br /> 5K& qoq <br /> EHD 43-02-006 WELL PUMP PERMIT <br /> 1/27/2005 <br />