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WELL/PUMP PERMIT <br /> • SAN.JOAr'JUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 186$EASt HAZELTON AVENUE-St'OCKTON CA 95205- (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> A fy� yy� it <br /> CROSS <br /> JDa ADDRESS • � . S� F J�C�� .. ..1� ._. CITYIZIP S `�- ' <br /> CRtlSS STREETa✓e- //^.f`.APAJ.,n..:(,J��Ib+. Q/JJ�Jr/�/�.+ -PARCEL Sac �� LAND USE APPLICATION�t <br /> OWNER NAMC -K.....!X....,.....,..!- -.. �I`^L.���.�-f------ ._............ PHONB....:.: .........Y....__.�.._...... 'A. <br /> OWNER ADDRESS CITYJSTATIEW <br /> CONTRACTOR ,i _...__ _.._.__...__ PHONE. ...... �_., ......,..�__l <br /> CONTRACTOR ADDRESS_. \�/ J` T �'. �kl. ./ r fGY1STATE/ZIP <br /> R � ._ !,_Q ('„ SFS/✓�t(,J <br /> SUBCONTRACTO !'_"'_-"_........Y,L.I�llI,r''fj,�,,. C PHONE <br /> SUBCONTRACTOR ADDREs9.,ai/. i/ +� i/�GG. . CITY/STATErbP tl ft-,bn,(A <br /> LICENSE 457 i:: C-61 D49 ::: OtharNUMaER ExPIriATION DATE_.. <br /> DOMESTIC WELL SAMPLING:(,J General MinerallColiform Bacteria(4391):"Dibromochloropropane(439?),,,Arsenic(4393) <br /> INTENDED USE DomesUcJPnvate Irrigation/Agricultural industrialWatcr Quality Monitoring ;Soil SamplinglCnaracterization <br /> r' Public Water System <br /> H ckftfranl from Owner. 4Vatax System Nemo (.oarWC Name or PAana Number <br /> heg OF WORK C New Well Replacement Wall Weil AlterationlModifcallon ;Other <br /> ii el ag5 i•(ielHQGhniCal.... #or tsonr:g: <br /> L: <br /> Monitoring Weli(sJ. .__... ... #of Wells .;Sell Barings)..___—__ _. <br /> L..Out-Of-Service Well „Out-01-5ervice Well Renewal Cross-Connection Repair <br /> rNew Pump Pump Replacement I"Pump Repair Raise Well Casina <br /> — —I <br /> WELL,CONSTRUCTION ,/� � <br /> Drilling Method r” Mud Roter Air Rotary !'MAuger Cable Tod Push Point Other � <br /> Proposed Well Depth_ift Excavation- � in dlamotar Open Bottom Gravel PacIdGravel Size diamr ter <br /> .:: Conductor Casing in diameter f Conductor Casing Depth_..__....__.r_------—ft <br /> Well Casing Diameter_in Thickne;FaugelAS"FM SiltedSteel Plastic Stainless Steel Other <br /> Grout Seal Depth_ft {/Neat Cement(941b bagl&-10 gat water) Sand Cement ., _ ..,.._sack m417 gal water <br /> Bentonite(20%solids)/ Other_ .........:......... <br /> Grout Placement Method Pumped Free Fall Other Rewdant.1 Accelerator(name) <br /> PEDEA7AL Installed By Driller Pump Contractor Other <br /> Concrete Pedestal::Dimensions:Width it Length_RThick in Christy Box `.: Stove Pipe <br /> 1Y4 Submersible::;Turbina "i Olhar HP Pump Sat—ft Standing Water Level Pt <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. y <br /> M tANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)9f53-76)9)7 <br /> SIGNEt)., � � _— TITLE eM. .-- DATE <br /> l l <br /> Alf,, <br /> IqQ�� � <br /> °° ,y �'� - <br /> 3 f <br /> P A TMENT U E Ny� <br /> Application Accepted By tate __1" Area <br /> "�/J//�J� Employee IQN <br /> Grout Inspection B Date T EciAL 4ltoil Permit <br /> PumpInspection,By _ � Date _ WAIVER Received <br /> Soil Boring Inspection By Date _ _ Constructed Well Depth <br /> COMMENTS <br /> PE SC Received Chaco/ Amount Data Permit) <br /> Invoice# well IOtJ <br /> Ca 1 Cash lRemiltied Service Rogues <br />