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WELUPUMP PERMIT <br />1 SAN J OAQUIN COUNTY ENv RonmENTAL H=xTH DEPARTVZNT 1868 EAST HAzr.LTm AvEww - SToonON CA 95205 - (289) 46$3{20 <br />NON-REFUNDABLE PERMIT CALL 209 9W697 FOR INSPEE22= EXPIRES 1 YEAR FRoM DATE ISSUED <br />IJoe R <br />ADDESSy ctTralp �] G <br />r <br />CROSS STREETt'1wry <br />AP%N PAROEL Scm /LLAAmo Use APPUCATiom ii <br />I'. OWNER N wE J _ V I... L P In <br />p <br />be <br />d (n <br />new <br />OWNER ADDR� <br />I <br />CONTRACTOR <br />CONTRACTOR ADORFss v <br />SUBCONTRACTOR <br />i <br />SUBCONTRACTOR ADDRESS <br />LICENSE 1-57 <br />GEOGRAPHICAL INFQRMATIC <br />INTENDED USE r 001TIe500/Pmrate Imga00NAgricum tai indu50Tal vvwer (itlairly ung JOe tiampKng&;nataCtarMaaOr <br />Public Water System <br />N ddferem from O -.r or Prov <br />-_ - --- <br />Pty) F <br />IV _ % )VATd/<ldP Utv , r , 1 <br />C-61 6-09 C4her�_ NUYBim W 10 ZxrotAmoh OATL <br />N: Coordinates X Y Towrnahlp _ R2nge Section_ <br />TYPEQF WORK New Well Replacement Well Well Afteration/Modificabon Other <br />Monitoring Well(s) iF of web Sod Boring(s) O d bUVW Geotndncal s dberfngs <br />-OfSennce WAROut-DfSerice Well Renewal Crass—Connection Repair <br />ew Pumo Pumo ReoLwament Pumo R rz, Rase Wall Casing <br />Drileng Method hMrd Rotary Air Rotary Aixw Cable Tool Push Point Otter <br />Proposed Well Dept ft Excavation r diameter Open Sodom Gravel PacidGravel Six in diameter <br />Conductor Casing in diameter / Co lductw Casing Depth ft <br />Well Casing Diameter L in Thicimess/GaugeJASTM Sched Steel Plegic Stainless Steel Other <br />Gran Seal Depth ft Neat Cement (94 ib bag/5-10 gal water Send Cement sack mm7 mal walk <br />Bentonite (20% solids) Qtur <br />Grout Placement Method Pumped Free Fall Other Retardant I Aoedetator (name) <br />W <br />D <br />a <br />P <br />�l <br />9 <br />W <br />PtMESTAl- Instilled By Driller Pump Contractor Other <br />Qoncrefe Pedestal Dhnenslon s: Wldtt ft Langth R Thkk in : ChrWty Boz Stave Pipe <br />au —up Submersible Turbine Other HP Pump Sot ft StiiindlngWater Level ft <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN ` 1 <br />JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS W <br />CURRENT AND ACTIVE WM THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL J <br />WORKERS COMPENSATION LAWS. <br />MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />SIGNED Tri DATE <br />rump Inspemon oy <br />Soil Soong Inspection By <br />COMMENTS <br />wTR <br />Date Cor <br />PESC Received ChecldV Amount Permiq <br />Code, Info By Cosh Remitted Dob Service Request <br />� I � <br />EH-- =>r,E <br />4nG 12 <br />�� 6 <br />ECEIVED <br />JUN 0 7 2017 <br />HE4LrH <br />5�POJ-OS L4// <br />WSJ. P -W PERWT <br />