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fir WELL/PUMP PERMIT SAN JOAQUIN COUNTY ENIRONAENTAL HEALTH DEPARTMENT 600 EAST MAIN STREET-STOONTON CA 95202-(209)41111-3Q6 NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED Joe A3DREW 2IOop �. RL,6PN//0D 04C,,MPP -0401 , 95L 4o CROSSSTREET Cldfen!61tJ?T, 5' FL IAPRIM-DEU'IS PARCEL SIZEM(P LAND USE APPLICATIONJ OWNER NAME PHONE OWER AOgESS TCRYISTATEMP CONTRKTOR PONEO 96 -3 76t CONRACTOR ADDRESS 4902 166frVIe�r w,4q cm/sTATErDPL{./.V/r91Q SUBCONTRACTOR ezD PRONE SUBCOW ACTORADOREsa CMISTATUMP LICENSE C-57 ❑C-11t ❑D.09 0 Other NUNeER62kfr Doo EXP RATONDATE2- GEOGRAFMCALINFORMATNIN: COO i"$Wi% Y TownaRlP_ Rang,_ Sasdon_ IIRENOED USE ❑Domeslk/Pnvate ❑IRigaNOWAgdOUNIUMI D Industrial O Witter OUallly Monitoring XSod$ampling/Characdc!i ation ❑Publie Warner System "` Ndabran an Wear s,sim Nemit einem TYPE a WORN ❑New Well C Replacement Well ❑Well AReratlonlModihcallon ❑Other ❑Monitoring Wall.)_JOTWells ❑Sod BOrirg(s) "'mere" XGeotechnical + _4r°"k� e ❑Out•OISerNoe Well ❑OM-04SerAm Wee Renewal ❑Cron-Connection Repak C New Pump ❑Pump RePlacememl O Pumps Repair D Rest Well Casing WEU CONSTRUCTION - O Drilling Method O Mud Rotary O Ah Rotary Auger ❑Cabin Tool ❑Push Paint ❑ Other n.lr O Proposad Well Depth !O-15 R Excavation Q-6 In dlMneter C Open SoRom ❑Gravel Pa&jG dVsI SIZe in diameter 0 nConduGar Casing_In0ameter / Conductor Casing Depth fl Well Casing Diameter_in TNcxness/Gauge/ASTM SUled ❑Steel ❑piaa11c G SWnkss Steel ❑Other Grout Said Depth fl ❑Neal Cement(911 Ih Deg/'to gat Wetaz) ❑SaM Cement sack mix17 gal well ❑Benlonile(20%solids) Of Other '501, 6W TFL4M( - "o 4 W Grout Pincement Method O Pumped ❑Free Fall ❑Wier 0 Retamanl I Ascemrator(name) Ramer Irsmlmd ey ❑Drilkr ❑Pump COnbador ❑ Other ❑Concrete Pedeeml Dimanalona:Wdgt_R Length flTNck in ❑Chrity Box ❑Slew Pipe puMP 0 SuDmeMMeO Turbine ❑Other HP Pump Sel fl Stand- Water Lewl R I HEREBY CERTIFY THAT I 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 REWIRED LICENSE IS CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL y� WORKERS COMPENSATION LAWS. �U MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS DATE if i.� R< 7eY� w 1A��fi ref r-Y4 M' Y• V N .fir i111E �� 1 _ D L DE PARTMENTU E ONY. Eid.',4U Application A:NepleA BY Data L3 g 4 ..••••tee - Emy 11DJ L�9°f 49 Grout InspecUdn By Dam SPECIAL WgH Permit7 Purtp Inspeddon BY Dam -, ,/ WAIVER Reeeided Soil Borl Inspectlo9BY Dale /.Y�/9" CaruWemd Well Depth h COMMENTS R/ /w n�'1ff�'/o'+ IFAG.¢7 '{'-13;/�' }� •/ /YG/ .�/ ry.�f }1 7 Sc Recemed c"I Amount Date Perm III IntroleeJ We111DJ MO B C RemHmd S.M.Re .M9 1791 ya -ill ENo.aae soAm wnL�PIAMIRpsar i.