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03-28-12;'16:11 12094683433 ; <br />WELL/PUMP PERMIT <br />SAN JOAOUIN COUNTY ErmRONYENTAL HEALTH DePARrTMENT . 600 EAST MAIN STREET-STOMON CA 95202 (2nol 4M.0114211 <br />ON -REFUNDABLE PR.RMrT CALL. 209 933.7687 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />�OrAonREsa Sy 1 lel. �rC Qrlk `1t ne R .l J clTylatP�� C CSC I C 5 3 T to <br />OtOnSTIItET_. 1/�• �' �` APN .,`�L D �0'01a Et.SIZ8"`3 LANol7sC-)A/RICATtCNaX <br />OYMQtt PtAme tS , r,(N e 5 \--I _J f� rJ`A _ PHONE � - 1 t7 E1 • $ 33 . 3y � to <br />OWNER ADOReaa 5��`y���� � V OL C1A 41 C\ a f� Crrvl8TATURIM 2 C (Lr -,l t, LA Q5 -s-1 � <br />CONTRACTOR GF U ' --) 1. 5-0-Q - (----------------------1---------, PHONA t oA � �\ t L n- <br />CONTRACTOR ADORsfa _5 1 kT "1 13 L_.\ L C P Q LJ Ir CrlY18TATEtzrp ':S ac-( G. m e cZ \ o <br />SUBCONTRACTOR PHONE '5d <br />-38 <br />SUBCOMTRACMR ADOREsa CITY/8TATE/Z IF <br />LldlNfl ❑ CS7 C 61 0 D-09 0 Other ___________ NUNISCR Q Dgg1µTION DAri _ ! J Q ! 4 <br />GEOGRAPHICAL NPORKATMA, Coordinates X Y T-06hlp — Range Suction_ <br />11I MPED USC 0 Domesfc/Prlvale 0 Inlge9aNAgrlouliurel D Industrial 0 Water Oueilty Monilodng ❑ Soil Sampling/Charaderizntion <br />0 Public Water System <br />e @naml6em �.,wator ya m �iTaci' a ne um er <br />TYPb OF WORK D New Well 0 Replacement Well ❑ Well AttereUon/ModinwIlion su.7thar r ll <br />0 MonitoM Weif s ng() _ sor nnet, <br />g O # of walls ❑Soil BDd e D GeoleUmical <br />D Otd-Of-Service Well n Cut.Of-ServRW Well Renewal 0 Cross-Cannedlon Repair <br />Drtlllno Method ❑ Mud Rotary u Air Rotary 0 Auger D Cable Toa c Push Point `F( Other PU <br />Proposed wall Depth—ft . Excavation in diemeter 0 Open Bottom p GraWl PaWOrayel Size in diameter <br />❑ Conductor Casing in diameter I Condudor Casing Depth ft <br />Well Casing Diameter _L in ThIrknv3 /Gauga/A8TM Schee 0 Steel O Plesilc 0 8talnlees Steer L Other <br />Grout Seal Dupth___ ft D Neat Cement (941b bagl&10 ga1 Mater) ❑ Band Cement sack mWx17 gal water <br />❑ Bentonka (20% Sallee) 0 Other <br />Grout Piscamsrtf Method D Pumped 0 Free Fell 0 Other O Retardant / Accolereior (name <br />Plmis Installed By 0 Driller q Pump Contractor ❑ Other <br />Li Conomte Pedestal Dimension Width (I Lar th It Thlck In _I Christy pox D Stow Pipe <br />0 SubmanubleD Turbine ❑ Other HP Pump Se rt Slanding Water Level R <br />I HEREIFY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL HE DONE IN ACCORDANCE WITH SAN <br />JOAQUIN COUNTY ORDINANCES. STATE LAWS, AND RULES AND REGULATIONS, I ALSO CERTIFY THAT MY REgllOM LICENSE IS <br />CURRENT AND ACTNE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WORKER» CO NSATION LAWS, <br />NIMU HOURADVANCE NOTICE REt U'IRED FOR INSPECTIONS <br />��- <br />OEPARTMENTaU E /ONLY <br />Appsraaon Aaepted By ____ Date 3 ! Z <br />Grout inspection By Dale <br />Pump Inspection By Onto <br />Soil Baring Inapeetien By Data <br />COMMENTS . <br /># 1/ 2 <br />P r <br />1 <br />i <br />r <br />tP <br />I I r I I %%f%% r I I I I f 1 II11,,, f-- rr) /..7 W r <br />Area uN���Empioyee ID# . (� J <br />Sperm Well Permit <br />Wmv" Received <br />Constructed W911 Depth It <br />PE BCReceived <br />Code Info <br />B Cash <br />Amount Dats PerMtN Invoice s Well ION <br />Remttled Service ueet t1 <br />mss 3 rg <br />5Sr. <br />SNDraos <br />erefRe <br />WIELLf WPSAMR <br />