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11 I i WELL / PUMP PERMIT SM JOAQULN COUIITY ENYIRONSIENTAL HEALTH DEPART.'NENT 600 E.4n X N STREET - STOCRToN CA 95202 . (299146&3420 iYUN-KEFUNDARLE PERMIT EXPIRES I YEAR FROM DATE ISSUED 'os ADDRESS ,.ZP _ ( ^// ►: CROSS STREET__ APN � P.vtcELS12e OWNERNAME OWNER ADDRESS �j CtTYlS1':1TEIZIP � �(y �� CONTRACTOR/� ��• 'C Ll PIIO1/EG2-E/%'C-�/I/I-] `7CQ'7/(� CONTRACTOR ADDRESS 1D7DLi �r L46C %� Ct'IYlST.W.MP rAYZF7 pllfil 6-S l�'�f'F' �-/ SUBCONTRACTOR SUBCONTRACTOR ADDRESS C1 rv/STATFIL► LICENSE ❑ C-57 ❑ D-09 ❑ Other NVAME$ ESPIR,TIo% D.aTE GE0GRAMCAL 1NFDaa fl'1fW- t+.r.ral..r.. v ------ -- soxtnorp_ Hauge Ssctton INTENDED USE ❑ Dourcstic Private Ur)gat3onAgricdtural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil Sttntpling,CheractLrt�atirm ❑ Public Water System If diff--..... Reo:O- - Wan S1x,m Nam:• Conry s Ns or Phos Number .. —.1 W rceptaccrnent wcu u welt AlteranowNlodilication O Test Hole ❑ Other ❑ Monitoring Weil(s) n bvot.s,Rs ❑SoiloD�`r'4 �' a®be. afb.viog: X31s) ❑ Geotechnical ❑ Well Destruction ❑ Out -0f -Senate Wei n WELL CONSTRUETION DrMkg Method ❑ Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tod ❑ Push Point ❑ Other Proposed Wen Depth ft Exca,ation in diameter D Open Bonom ❑ Gravel Pack i Gravel Site in diameter ❑ Conductor Casing in dituneter ! Conductor Casing Depth ft Well Castog Diameter t Z -i. Thickness/Gau,,ASTM Sched sx1 ❑ Plastic ❑ Stainless Steel ❑ Other Grout Seal Depth it ❑ Ncat Ccntcat t941b bag:' S-10 atay ❑ Sand C.•m m �Hsack m[r; 7 gal water ❑Bentonite (2Q9e solids) ❑ Manufacturer Spee % solids _ en \ams ❑ Specs on Fil: ❑Specs Submitted Groat Plaee®eat Method ❑ Pusnped ❑ Free Fall ❑ Other ❑ Retardant : Accelerator (name) j PEDEaTAL Installed By ❑ Driller"94t.mp Contractor ❑ Other trete Pedasta! Dimensions: (Width_ R Ira ft Thick in ❑ Christi Boa ❑ Stove Pi pe PUMP ❑ Submersible NfitLurbinc ❑ Other HP _LCIC�_ Pump St,, ft Standing Water Level ft WELL DFsrRUCTios ❑ Open Bottom ❑ Gravel Pad: Cl vocasca ❑ Other t'. Well Diameter_ in Tool Depth ft Depth to N'aur _ ft L3 Casing to M Perforated from R toft Sealing Material ❑ Neat Cement M4 1b bag ,'5 -legal roarer) ❑ Sand Cemaat rack mL-; 7 gat water E3 Beatonite Pellets ❑ Bentooite 00% solids) ❑ Manufacaurr Spec % solids _ 4a Name ❑ Specs On Fih ❑ Specs Submitted PtaeemM Method ❑ Pumped ❑ Free Fall ❑ Other ❑ CotryttMs with Mushroom Cap ft below grade ❑ Complete to Existing Surface Pad ---- --- - --' aara nrrrd�.grrvv 4-" IHAT THE WORK RTLL BE DONE IN ACCORDANCE WITH SAN JOAQULN COUNTY ORDINANCES, STATE LAWS. A.YD RULES .IND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND VE W)TH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD A.YD THAT I AM LY CO.MpLLIYCE WITH ALL L�4�Yi/AL/" ► ��tari�at► Aral•�� uuiY//GJuuuuIN I��uuuMy,Mrm uuuuzMMMMOMMMM MM MOUN■ fMONO amam0 mammal ■MMUMMOMM �� ��MM i�uuuuuu�uuuu�uuul■auuul ■muuuu-uuuu�uu ��P: ■I Oa�r•��MILIPME On mammal mmmmmmmmmmm MMMASIa�� ■��1•��r�� Now uuuu�uuuu/uuuu�ullu ��uuuuuuuul•uuu kaMM&� uu�/uul•�uui•u�uuuu��1'I� uuuuouuuuuuu ir�� 1•��Wi010WIM /mmommm��I��I�a /I':ti7�■ �u�uur•uuuuuu�uuuuu&i'MUM C ■ RNuuuul•ON MalahnammaIMOMM uuuuuuu uuouWIN ��u�u��!•�.��!•1■!•aa • . . t. 9!11:2007 Ch&4k r V J�0( -::v'70. W mart -17. Dv INazeN'os reit rerttur ane DaCrarat MAM