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WELL/PUMP PERMIT <br /> St%JOAQuNCot;%TyEN„tRWiIEATALHEALTHDEP.%RTMk.NT 600E.4nXkmSTRErr-STOCKToNCA93212-(209)468.3420 Ll <br /> k <br /> i ;VON-REFUNDABLE PERAHT EXPIRES I YEAR FROM DATE ISSUED <br /> 'oDADDRESS oOt v, __ CttslLte_ I-1IVa4 <br /> CROSS STREET ate` /� _ (APV 0” �%'� -i`(�`�I P.UtCEL SIZE <br /> ON SkR N.tNIE r � "G I d c A `�ct K P,,.,.:_j2�fAlp. � <br /> OW-ER ADDREss 0 0 Y ',)Orr/��..�./�/j G CITYISf.tTEMl- 44 I 2- <br /> CO%TR.ICS'OR Ey ^� '�I RZ Pgja <br /> CO�IR%CT'OR MDRE551a�to� s //w y_?6_ Cil`"/SrATF171P t l%5 9540?507 <br /> S%E(:Ot7RACTOR PRONE <br /> SUDCONTRACTOR ADDRESS CIT`YSTATMAP X _� i <br /> LICENSE O C-5 i C-61 ❑D-09 ❑Otho VtNaER 067V841—EKPIRtTI4�D.%TE i' <br /> GEOGA%PH[cALi�fORat%Lo%: Coordloates X Range Seaton---- <br /> 7EN0 Domestic. raw tion,Aericulturai 0 industrial C Water Qualiq Mowtoring 0 Soil Saraptia.,Cluardeterlaarim <br /> Cl Public Winer System ---- <br /> D'dthae ftcc:11,-- Wag Sl mm X.— Ceeta\an;v I'hcro Vuc2+- <br /> T%PE OF WORK 0 New Wci O Replacement Well O Wc1i.Altcrat=MtodiiIcat(on O Tog.1101c 17 Other ,. <br /> 0Monitoringwews) "=bv"fw,its OSoi1P.onVs1 """"towe, ❑Gcotecbmui <br /> 0Well Desrrtudon 00m-0f-&-,viceA'e1i 0Out-OFSmii WellRencaal <br /> Ncw 0 PunV Rcolaccmal. 0 Pump R: it 0 Cross-Con=xion R. 'r <br /> TELL CONSTRt ho- <br /> Drilling Method 0 Mud R.ntary 0 Air Ro ary 0 Anger 0 Cable Tool 0 Push Point 0 odw,_ _ <br /> Proposed Well DIuth —f Excavation in diameter D Open Bottoms Cl Gravel Pack t Gravel Site in disateW <br /> ©ConciworCasing indiameter I Conductor Casing Depth fl <br /> Well Casing Diameter—in Thick'nes>'Gaup-,ASTM Schcd 13 Siccl O PlaAic 0 Stainh s Steel 0 Odter <br /> Grout Seat DTth fu C3\cat Cem:ut;9J!bbag_'3-10gniaawe ❑SandCcrrtcr jack n;ir,7gal mater <br /> 0Bentwtirot20esolids) OManufa.-:urzrSpec°bsolids Ao Name_ 0SpasonFila DS=sSubmitled <br /> Grotut Ploceunent Methed 0 A ,,d 0 Frce Fall 0 Other O Retardant,,Accelerator(name)_ <br /> PEOES"r:LL la"alled By O Orilla 0 Pump Comtractor 0 001cr---.------._---. <br /> 13 Coaerete Pedestal Dimensions: Width______R I.eneth P Thick in ❑Chrlsh,Box M Stave - <br /> PiRiP S•abmersihic turbine C]O:her IIP PtwpSct 1w=ti SLjndiagWrTLe,J It <br /> WELL DESTRtCttON C3 Open Bonom 13 Gravel Fack- 0 Uacac:d d Mer —Well Diametr_in Totai Dcpdt —ft Depth to Water _fr O C s ere to be Perforaud fram__li to ft <br /> Scaling Material 0 Neat Cement r94 lb bag:3-70gai%arvq 0 Sand Cctneut racktrtir 17 gai rater 0)3eaumute Pellets <br /> 0 Bentoutte i20:'s solids) 0 Mlanufacturur Spec':ro solids % Name 0 Spwson Fil_ 0 Specs Submitted <br /> Placetxnt Method 0 Pumped 0 Free Fall 0 Other— <br /> C3 Cot let:vtith Mushroom Cap--ft below Stu& 0 Complete to Existing Surtitcc Pad <br /> P HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE I\ACCORDANCE WITH SAN <br /> JOAQUIN COUNtiY ORDINANCES. STATE LAWS.AND RULES AND REGULATIONS. I.%ISO CERTIFY THAT?TY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA C'ONTRAC'TORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS CO. 7 <br /> SIGNED T.TlE D��" DATEt/ I I/ <br /> MENT <br /> EIVED <br /> 2017 <br /> IN COUNTY <br /> MENTAL <br /> PARTMENT <br /> DEPARTMENT USE ONLY J <br /> Applicat3au A-clx By Dole 1() I I 17 Area `/ Fitq byes ID= <br /> Grsut Inspection By Date 0 SPECIAL Well Permit <br /> Pam log-edonsy DatePal w-I h 17 WAIVERReceived <br /> Destruction Inspection By_ Dat.:, _ Cousirue[ed Well Depth_. R <br /> COMMENTS <br /> PE Sc Reeel"d Clsecw Amount to Perttaw Invoked WeOD)p <br /> Coda Info Club Remltfd S"VICULem N <br /> 41t0 0 7 <br /> ERD 43-02-006 WEB '.i'ell Permit and Dsktar:r.:.doc <br /> 9.t 1 2047 <br /> III <br />