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IWELWELL/PUMP PERMIT 601 <br /> SAN JOAQUIN COUNTY ENnoscAMENTAL HEALTH DEPMIMENT 600EASTMAINS11AlET-STOCKTgMCASSID2-(209)468-UN <br /> I a NON-REFUNDABLE PERMIT CALL 209 983-7897 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB AooREse o`L SIO ' Al - d-Z-Z->EAID APW <br /> CITyrzP Snc1r-7-D Al 9S2(S D <br /> CROSS STREET 2^9-(3 0 <br /> Y APN /O/-2tP-[/ PARCELSM43' �AIID USE APPLICATIp1# <br /> I I A� 'fvr*F Ln <br /> OWNER NAME '7TtLJ�/N£L I C.Fr�a.L.(Ott[SE TJ'L PHONE $ <br /> OWNER AOORESS/1^��\ �� T CT•ISTATEMP -f�ntf ..,,E <br /> CONTRACTOR W_ NV6 {...A `- ,�`��IC� C�jI .y��G�. PHONE C=04k)�YT-051t <br /> CidNTMCTpR AODREas \(JV `�W �\\-r `- CIIY/STATP/LP pQC- <br /> SMCONTRACTM �+T�C PHME ��-�J� <br /> SMcartRACTORADORM CRYISTATFZW \�A �J�C p 1� as o <br /> LKvitse G5/ ❑C-61 ❑D-09 ❑Other Maxims-=1 LL EKPIRATON DATE <br /> GEOGRAPHICAL INFORMATION: Coerdlrada,)( V Township_ Range_ Stolon_ <br /> NRENDED USE - DOme311dPdvele L7 Imga tn/Agnculi D Industrial D Water Quality MonOodng NON Sampling/Charactenmtlon <br /> J IPaPllllannfO <br /> aiewn System water sysulun <br /> Naarea re u <br /> TYPE OF WORK D New Well �Replacement Well U Well Alteratlon/MOO1RTalion D Other '- <br /> DMonibMgWalls) t/of walls ❑Soil Banng(s) AcfN ,, XGeotechnlcal e or When <br /> D Out-Of-SeMce Well D O06Of-Service WNl Renewal O Crose-ConnectionRepair <br /> New Pump ❑Pump Replacement C Puimp Repair [I Rahe Well Call <br /> WELL CONSTRUCTION <br /> Drilling Method D Mud Rotary D Air Rotary XAuger ❑Cable Tod ❑Push Point ❑ Other <br /> Proposed Well Depth 5_W R Ez®wfion -A- in diameter ❑Open Bottom ❑Grawl PaCPJGrewl Sim In OsmeM gJ <br /> I =Conducbr CaNng in diameter l Conductor Casing Depth ft <br /> WeII Casing Diameter_in Tnickness/GauglEASTM Sdsd ❑Steel C RMI]c C StalMess Steel �Other <br /> Grout Seal Depth R at❑Now ant Ib 0 <br /> P ,v ( ga(weter{ ❑ f sack rrux/l gel <br /> Bentonite(20%Solids) ^otlNer r1 \ f-- SCG ` <br /> Grout Placement Method Pumped ❑Free Fall DOtiror ❑RefPdent I AoosWaw(neme) G <br /> PEo� Installed By ❑Driller C Pump Contractor D Other <br /> CDllereta PedsoUl Dime We :Wide_ft Length ft ThIck In ❑Christy Box ❑Sawa Pipe 10� <br /> IBM Submersible_Turbine n Omer NP Pump Set ft Standing waterLewl ft <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN O{rC <br /> -�JOAQUIN COUNTY ORDINANCES, STATE LAWS. AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> I <br /> MINIMUM 94 _ R A V NCE NOTICE REQUIRED FOR INSPECTIOf S-P ASE CALL(209)953-7 911 <br /> ' BIDt1EO TITLE DATE <br /> M 2 � q`•4'I Y <br /> w <br /> DEPARTMENT USE ONLY <br /> l Application Accepted By ` _ Date (9 (f Area .._. ._ —_ -_Employee ON If? <br /> 77 <br /> Grout Inspection By Date ❑ SPECIAL Well PerlRlt k <br /> Pump Inspection By Dale ❑ WAIVER Received 7 <br /> Sell Boling Inebaclgan By Constructed Well Depth }! <br /> COMMENTS <br /> Code 11=0Ra�MMd IgmRbtlData Sella 6 Imbibe Well ID71 <br /> I <br /> END AUG <br /> BD6Da _ WGLA'IIMPPE1reT <br />