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WELLIPUMP PERMIT <br />SAN JOAQuiN Cowry EEmvrtoNmEN-. AL HEALTN DEPARTMENT 7868 Eur KAZSTaN AVDIM-STtxxraN CA 95205 - (289) 469- t <br />NON-REFuNr,rr CALL tag 953-7697 FOR Ips EXIMM i YEat FRoM DATE IasuED <br />JOG ApoRESS M CIrry" CC; <br />__ 1 <br />OWNER NAME � ✓ l ��CAAN t7 6/1PAr-ruv L.tle Lt o:A 5ttoN il�_ <br />OwrEx AtN7RE55 p 64 <br />G�yl 1Y I 1 LG A7>� 1hClo�C((�� <br />CONTRACTOR PIIaNLLI <br />CONTRACTOR A.�REss a �•t tv &t <br />Cis <br />StlacoNTRACroR <br />Suvicoynt <br />Awitim AL <br />UCEMSE OG C -6T a09 Caner L y (�G• b cKP.t-40M OATC a <br />GEOGRAPWCAL 1 TION: Coordrufts X Y TaWrAhlp _ Ranger S*M—_ <br />VO (, INTMNK= USE , Domesb6private IrrlgatlaNAgrlcLffJZW IndLsSftl WSW OUSKY MortYTrtrtg son <br />Public Water System <br />TWE OF WORK New Well Replacement Wen Well After2bon/Moddication Odd <br />Mondonng Wett(sI A or watts Sod Boring(s) i dOpnrw Gagtilich cal <br />Out -of se-cl! VOM Out -0t -Service Well Renewal C fi�yair <br />New Pump LL Papp Replac *rt f .Pump Repair Wise Well Casing <br />Vv <br />1z <br />X <br />SQtMTM4q!!9-w <br />DrilMng Metlrod <br />Mud Rotary A` Rotary <br />Auger Cade Tod Ptah Point OBfar <br />0 <br />Proposed Wen <br />Depth ft Esavabon <br />in diameter Open Bottom Grand PadJGravel Sae <br />in darrteter <br />CaductGr Cascng <br />in d ffww / CorWuctar Cas+ng Depth R <br />Wee Cuing <br />Dtamew _ m TMdmrmsN3atrgelASTM <br />Schad Steel Piaatic Stainfaas Stael Other <br />Grout Seal <br />Dow ft <br />Now Cement (g4 m b&95-10 gel watarj SPM <br />SS& MWd7 gat water <br />f1 <br />Bentonde(20% solids) <br />Grout Ptaoement <br />Mettad Pumped Fro-- <br />Fall Other Retardant / AcodeaW (name) <br />f\^` <br />ny r-wi r P_-,., (w.x I <br />Concrete Pedestal Dlnanslons: Width ft Length ft Thick in Christy Bent Pnpa <br />PUMP Submersible Turbine Other HP �__ Pump ,� iI Standtrlg Wager Laval ft <br />HERESY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br />JOAOUIN COUNTY ORDINANCES. STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY TUC MY REQURED LICENSE IS <br />CURRENT AND ACTIVE VNTH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM N CO1111D1UANCE WITH ALL <br />WORKERS COMPENSATION LAWS. W <br />MINIMUM 24 HOURADVANCENOTICE REQUIRED FO INSPE/C�TlIOMj <br />- PLEASE CALL (209) 9553-7697 <br />SIGNED I/y�.,.t/1�- / i idGL1.� �- TIT. d/ I ll 111 C�/� DATE • l UIL <br />A_ TMENT E )DN LY /�y�/ I, <br />Aodication Accepted BY -� Amu Ernployee 100 <br />Grout inspection By Date _ SPECIAL Well Pemtit ��J•� <br />sump inspecnon By Dam (� .= Wmvm RacWvsrd <br />Soil Bonng InsDect,ion By _ Date _ Cortatrucmd Wo Depth _,__ ft <br />COMMENTS <br />&C4140 VALA-.JPrEFe <br />40012 <br />