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WELL/PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304E WEBER AVE3F°FL-STMMNCA 95202-(2O9J NON-REFUNDABLE PERMIT CALL 209 9$0FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISS ry�� L.f1. I- fy�I JOB ADDRESS ISSVI/ eS• IrLPV}INArN Rl� CIIY/ZIP N Gq 1 1 ,,/� / CROSS STREET' /By( N D - I�LWJ/t I� APN LV'l-I �0 X07 �JPA�R/C�EL SITE Z I.Ig p OWNER NAME _�j 11'(I /M.MV.IIAtITK.S1 PnONE ZLY4=AV -1667) �^ OWNER ADORFSS /� 1L�(AC�•{ 116�,�� SM,I.�C FY CIiY/$TATUZIP�rR({•/�I/.../� .1LIy�G�� CONTERACEOR \ PyjAyA t- � Il__LIND/OG CC,c� 1��✓•IC PHONE 1ZVq-Z•S`/1r— 92f71S CONTRACrORAODRESSC ID 1O FY/rillC IAka-� CXii-, �H1.r4L1 CITY/STATWZIP JYDG.RIO/K,I CIA- 0pp��6/-2016 O SUBCONTRACEOR JOC LYYrJ4N PHONE ZD4 - 4hS-C3 TIZ (/J $UBCOMMCEORAODRFES 15'r,5 14yo,-,4 A(I Ii e CITY/STATEErbl'l' V TDddn, 1 clI L s LICENSE C-57 ❑C{I 0D-09 ❑Other NUMBER GOO EXPIRATION-��D�AIIITE 14/30/D GEDGMPHICALINFORMATION: COOrdlmhx X Y Township Rene_ Section INTENDED USE ❑W.Mi&Pd.tc ❑ImplioNAgricultunl 13 Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterhation f.�s ❑Public Water System 6 ITdW iVe rA U r. her ynam ams Contact Karen or Phone Neenber TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Altention/Modifiauon ❑Test Hot. ❑Other ❑Monitoring Wall(a) relnee-fwelh ❑Soil Boring(a) nome.roreo4nar ❑Gortamial aumemoreodaF P(WOl DwWction m�'l (IDj/ ❑Om.OFServce Well ❑Om-Of-Service Well Festival New pure ❑ laeme ElPturpRe,sair ❑Cross-Connection Repair WELLCONSTRVCTION Drilling Method ❑Mud Rosary ❑Air Rotary ❑Auger 13 Cable Tool ❑Push Point ❑Other Prepared Well Depth R Escsvatier in diameter ❑Open Bottom ❑Gravel Park/Gravel Sim in dimemr 13 Conductor Cuing in diameter / Conductor Casing Depth R Well Casing Diameter_in Thwormia/GaugolASTM Sinned ❑Steel ❑Plastic ❑Suinlem Steel ❑Other Grout Seel Depth R ❑Neat Common 194 lb 1ag/5J0ga1 Water) ❑Sand Cement mckater l i gal water ❑Bmtonile(20%solids) ❑Manufacturer Spa%solids_% Name ❑Season File ❑Specs Submined Grout Placement Method ❑Pumped ❑Fret Fell ❑Other ❑Renrdem/Accelenwr(mme) PEDESTAL Installed By ❑Driller ❑Pump Conlrumr ❑Other ❑Concrete Pedestal DlmmrImm.: Width_R Length B Thick in ❑ChFlsty Bax OStove Plpe Pump El Submersible 13 Turbine 13 Other HP_ Pump Set R Standing Water Level R WELLDESTRUCNDN ❑Opsn Bonom ❑Gavel�ck ❑Located ( C!Other Well Diameter Zin Total Depth R Depth to Wet.2y�A R O Casing to be Perlbmed from A_R ii R Sealing Material KNnt Cement(94 fh hag/J-logo win) ❑Sand Cement sack once/]gal voter ❑Bemonite Felicia ❑Bemmmim(20Y4 solids) ❑Msnufatum Spec%solids_% Name ❑Specs on File O Specs Submiued Plaeement Method I*umped 13 Free Fall OOther ❑Complete with Mushroom Cap fl below grade ❑Complete to Existing Surface Pad 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. y/�� M� IMJU,M 24 HOUR ADVANCE NOTICE RE1QU�lI�RED FOR INSPECTIONS SIGNED 4�' TITLE ��'fG�'1 �(A�4 DATE Z/63 zm , m Application Accepted By V LVwf &&<A' Date 6-�-•�3 Ara '2 1(o �EmPlOyec IDp Greco Inspection BY Dan ❑ SPECIAL Well Permit Pumphispection By Dam ❑ WAIVER Received Destruction Inspection By Date G la 3' Constructed Well Depth_R COMMENTS PE SC Amount Che Received Die Permit/ Invoieeii Well Has Cod. Info Remitted By Service Re uertIt 3-73 ibl — S 003 035 EHD 03-02-0W MASTER WATER WELL PERMIT snrzlloz 1 CO Py