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WELL / PUMP PERMIT <br />SAN JOAQuIN Courrl'v ENviRoNatENT TH DEPARTMENT 304 E WEazR AvE 3 wroN CA 95202 - (209) 408 .w20 <br />NON-REFUNDABLE PERMIT CALL (209) 953-7697 FOR INSPECTIONS F S 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS 9 F�6.����.) C' ��t,qI Cal C./Z. �A.�,��;�� � <br />e <br />s39r <br />(�& <br />CROSS STREET IJ9n 9 APNA1 I — 0 y0 " / 1 SIZ/E •/V- 4 ` LAND USE APPLICATION # <br />d <br />QPARCEL <br />/; <br />OwNERNAME CAe-,� dqA %ve X4c %Fr e.��l1 C.r�►m f�Ru rAiK�(�-��'i PRONE�/_�9-a.I /-5� 9� <br />r <br />OWNER ADDRESS ;© .BOX S-10 O CITXBTAT MW /�t'JC'� `-"•M-pt C/4 9sa3r <br />CONTRACTOR PHONE <br />CONTRACTOR ADDRESS Crr'Y/STATE/LIP <br />SUBCONTRACTOR PHONE <br />SUBCONTRACTOR ADDRESS CITY/STATE/LIP <br />w <br />LICENSE ❑ C-57 ❑ C-61 ❑ D-09 ❑ Other NUMBER EXPIRATION DATE <br />GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section_ <br />INTENDED USE ❑ Domestic/Private ❑ IrrigaU /A cultural ❑ Industrial ❑ - ter ty Monitoring ❑ Soil Sampling/Characterization <br />id Public Water Systemr� hien <br />(� <br />[f dltTereat from 0".-nleRr r , stem me C..tnct ome ocPho. Nu r <br />=\" <br />TYPE OF WORK ❑ New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other <br />❑ Monitoring Well(s) # of wells ❑ Soil Boring(s) set bonngs 13 Geotechnical #.f bonapaZj <br />ViOut-0f-Service We ❑ Out <br />y. -Of -Service Well Renewal ❑ Cross -Connection Repair <br />❑ New Pump ❑ Pume Replacement ❑ Pump Repair <br />WELL CONSTRUCTION <br />Drilling Method ❑ Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other <br />Proposed Well Depth ft Excavation in diameter ❑ Open Bottom ❑ Gravel Pack / Gravel Size in diameter <br />_ <br />❑ Conductor Casing m diameter / Conductor Casing Depth ft <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑ Steel ❑ Plastic ❑ Stainless Steel ❑ Other <br />Grout Seal Depth ft ❑ Neat Cement (941b bag/5-10 gal water) ❑ Sand Cement ,rack mix / 7 gal water <br />❑ Bentonite (200/a solids) ❑ Manufacturer Spec % solids % Name ❑ Specs on File ❑ Specs Submitted <br />Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other ❑ Retardant / Accelerator (name) <br />PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑. Other <br />❑ Concrete Pedestal Dimensions: Width ft Length ft Thick in ❑ Christy Boa ❑ Stove Pipe <br />PUMP ❑ Submersible ❑ Turbine ❑ Other HP Pump Set ft Standing Water Level ft <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WELL 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 />N11NIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br />• <br />SIGNED TITLE 111 Ak4 DA <br />FIVEG <br />1 7 2006 <br />V1 <br />QUIN <br />EpqtC <br />N <br />�0fV7Y <br />I <br />NT <br />IL <br />DEPARTMENT USE ONLY <br />Application Accepted By � VN'' — Date L j7 til I Area Employee ID# �✓ <br />fff <br />Grout Inspection By Date ❑ SPECIAL Well Permit <br />Pump Inspection By Date ❑ WAIVER Received <br />Constructed Well Depth ft <br />COMMENTS <br />PE SC Received Checiclfl Atsatant Pesnitf <br />Cod Into ash Remitted Date Service Request # # We" tD# <br />3 o u •.. <br />EHDIO-VL.eaG. WELL PUMP'PEaM T <br />tlD7/ZpTS <br />