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WELL/PUMP PERMIT SAN JOAr,U1N COUNTY ENVIRONMENTAL HEALTH DEPARTMENT JW E WESER AVE P'Fl.-STOCICI'ON CA 95202 -($09)9611-3430 NOF REFUNDABLE PERM �IT'M CALL 209 953-7697 FOR INSPECTIONS EXPIRES �II YEAR FROM DATE ISSUED to JOOADDRE55 _ s'5-0^I[///�'^I J� [�U�S�` fille2VIfC qp CATV/IZIIP pLWYPI-l" 9:5530 m CROSSSrREET &�rT-�0L-411 /f //11 AIN /%(J -12.4 -06, PARCEL SIZE &3e ja D 01"ER NAME /I-o-�,r61rL SS (i� PRONF. Cts �/-� �)p OWNERADBRFSS-B& J4A9)501t1 (Y/X 1,79 CITY/STATFJLtP �LE�.YEg7 AA?7'D/// COMRACTOfl wwC--,,L-].,q-ek LW, 971.L�. TAle,/L1/ �PrRoNNg Z7�9- `1.6F 2--7671, CONTRACTORADDRESS 7./r1 L/ �!'XK A,/E //] CITY/STATIALIP�5/ Ck,VAI, Gra �J Lri� ONSSUCT _/i✓.q- /�_ (�FL-LG7_LJ!!/7 GOC-Y ("rP"ONE/9//r/1v^41o�p9057/ $5 5-IC42.5ES WEACTORADBRESS 2a, L� 519 CITY/SrATYIZIP A.OIC-$] PK-til 0D49 OOther NUMBER '3Z/560 EXPINATIONDATE /_r�� GEOCRAPNICALINFORMATION: Cnah Oordlmat, % Y Tawlp L Range Steilon_3 s- INTENDED USE ❑Dom.UdPsivme 0 lrrigation/Agriculluml ❑Industrial IG Water Quality Monimring ❑Soil SampiNg/Chamcterivntion ❑Public,Water System Ire'rt< fmm ria seem .ria .nun N.nere u TYPE OF WORK ❑New Well O Replacement Well ❑Well AheraloNModi fiction ❑Test Hole ❑Other numeer.r-le reaberorbona• ..6D O Monitoring Well(s)_ ❑Soil Boring(s)_ d E3 GeMachnieal mmbv.rbannga aRRb2 Well Destruction ❑Gut-Of-Service Well ❑Out-Of--Service Well Renewal O New Pump ❑Pump Replacement ❑Pump Repair ❑C.ss-Connection Repair WELLCONSTRUCTION Drilling Method ❑Mud Rotary ❑Air Rot., 17 Auger E3 Cable Tool 11 Push Paint 13 Other Proposed Well Depth R Excawlion in diameter ❑Open Haltom ❑Gravel Peck/Gravel Size_in tlianrc.r 13 Conductor Casing indiameser / Conductor Casing Depth R WeII Casing DiamMer_iR ThieknesdGauge/ASTM Schad ❑SON, ❑Plastic ❑SeM U,Sttel 0 Olhcr Grout Seal Depth B ❑Nor Cement(94 I6 Aug/5-/0 gal water) ❑Sand Cement ,raLR Mix/]gal water ❑Bentonie(20Ye Solids) ❑Manufacturer Spec%solids_% Name ,17 Specs on File O Specs Submillsd Grout Placement MetM1od ❑PumpM ❑Free Fall ❑Other ❑RenardanU Aecelenmr(name) PEDMAL Installed By ❑Driller ❑Pump Connector OOther ❑Concrete Pedestal Dimensions: Width 11 Lenglh_A Thick in ❑Christy Boa ❑Stove Pipe PUMP ❑Submersible ❑Turbine ❑Other HP_ Pump Set—ft Standing Water Level It WELLDESTRUGDON ❑Open Bell.. Orwal Pack aUncapal ❑Olhtt Wall Nitrate,Lo in Tond Depth /91 R Depth.WMm_/_YB ❑Coding..be PcMlomedfsom_/o ft In O Il Sealing Material ❑Neat Cement(94 IA Mag/5J0ga/Smarr) 1fSamiCcmrnn (0a3 .sockmiyl7plvmcr ❑Ben.nile Pellets ❑Demesne(2 %Salida) ❑MaMfiRcImr Spec%solids_%. Nan. ❑SPccaml File ❑Spec.Subetincd Placement Methal WPumped ❑Free Fall ArOlher I!C9E4L676(`d.'W V &—N&—L/ALV"ey j - F" /Lam ep omplcm will'Mushroom Cap-,T—11 below grade ❑Compinem Eniding Surfow PaO 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. I 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. I OU ADVANCE NOTICE REQUIREDDFO/R INSPECTIONS SIGNED L Trl'LE (^-IY 4 r DATE IO G l R MF DEPARTMENT USE N Y Application Accept B No, Amn Employee IDN + Grout Inspection By Data ❑ SPECIAL Well Permit I' Pump Inspection By I y Date ❑ WAIVER Received Destruction Inspection k k2A z(.,y,— -pate/U L7�12-� p� Constructed Well Depth R COMMENTS 1///riJy S nF/(n 3 rfIEC :'ie Ali H 71 .n�jsa Codes ��- PE SC Amount it.elved Date Permit U Invoice# WI Info RemlRed Cash SRe ueatp eII IDN B ervire 1 l50- 6 EHD 47-02-006 $11.00= MASTER WATER WELL PERMIT