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tWELL/PUMP PERMIT <br /> SANJOAQUINCOUNTYENVIRONMENTAL H, 'DEPARTMbM' 304E WEttERAvg 3`4 i7pCRTpNCA91202 -(Zpg)Mig.Sg2D <br /> NOPE-REPUNDABLl/E PERMLT CALL 209 953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED <br /> JOB ADbRE5s JKy n l <br /> I� CITYlZtP ! 1% 1 n <br /> CROSS SMELT 9ktil. wPN ZZJ PwaceL SlzE $ <br /> OWNERNAMElAM1 � Ern^ <br /> OWNER ADDRESS AWA <br /> S PHONE <br /> CrrYlSTATFIZIP ��/ 04,27= <br /> CONTRACTOR PHONE <br /> CON'r'RACTOR ADDRESS CITYISTATIi �../ D 00 <br /> gUBCONIt1ACrOR Pl IONE <br /> SUBCONTRACTOR ADDRESS CITYISTATEIZIP <br /> LICENSE 18C•57 0C-61 0D•09 ❑Other NUMBBa I It ON <br /> CEOGRAPHICAL INFORMAnON: Coordinates X Y Township Runge Section <br /> 1NTENAED USE ❑Domesti6lPrivare ❑IrrigatioNAgricultural ❑Industrial ❑Water Quality Monitoring ❑$oil SamplinglCharaetetia[ian <br />+ Q Public Water System <br /> IrdiMmt rram Ow ,: a er yaerm ■ma onNRr 6me a one u 5 <br /> Q <br /> TVPEOP WORK ❑New Well 13 Replacement Well ❑Well Alteration/Modiricariwt ❑Test Hate ❑Other <br /> 0Monitorin Well(s) —hoof—lir 'boo ftortna. <br /> 8 Q Sail Borings) ❑Geotechnical numbu ormunlp <br /> Well Destruction Cl Out-O&Service Well Cl Out-Of--Service Wett Renewal <br /> Q New Pump ❑Pump R latement 13 PUMP Rgnir ❑Crass-Cohnection Repair <br /> WELL CPNSTRUCTION <br /> Drilling Method O Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool C❑Push Point ❑Other <br /> Proposed Well Depth ft Excavation in diameter 0 Open Bottom ❑Gravel Pack 1 Gravel Sim in diameter <br /> C]Conductor Casing �indismeter I Conductor Casing Depth tt 1 <br /> Well Casing Diameter_in ThicknesUGauge/ASTM Schell ❑Steel ❑Plastic ❑Sminkas Steel ❑Other <br /> C rout Seal Depth ft Q Neat Cement(941b hag/5-10 got water) ❑Sand Cement Suck mix 17 gal waler <br /> 0 Bentonite(2V16 solids) E3 Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted $ <br /> Croat Placement Method ❑Pumped ❑Fra Fail Q Other ❑Rctardam 1 Accelerator(name) <br /> PEDESTAL In�{k{Ip_d By C3 Driller ❑Pump Contractor ❑Other <br /> ❑CaDerete Pedestal Dimensions: .Width fi Length n Thick in Q Christy Bax ❑Stove Pipe <br /> pump ❑Submersible ❑Turbine ❑Other HP Pump Set il Standing Water Level 11 <br /> WELL DESTRUCTIONOpen Bo':lom ❑Gravel Pack ❑Utrcesed ❑Other <br /> Well Diamacr rr 4!Total Depth fth to Water n ❑Casing to be Perforated from ft to 0 <br /> Sealing Maii 13Neat Cement ii 1h bag15-10gat ter) <br /> od Cement rack-ix?7 go]water 13Bcntonite Pellets <br /> T'Scr itc(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted <br /> Ptaeement Method xPumpod Q Free Fall ❑Other <br /> 1]Compli with Mushroom Cep ft below grade 0 Complete to Existing Surface Pad <br /> 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS,AND RULES AND REGULATIONS. ! ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> M IM UM 24 HOUR ADVANCE NOTICE Rf}FQU)RED FOR INSPECTIONS <br /> SIGNED TITLE fT DATELr_gZ` <br /> TV 1421 <br /> 7T g <br /> i . <br /> N <br /> PU 4 <br /> h a <br /> Application Accepted By IIEPARTMENT USE ONLYDate I— V— o-L Arty Employee 1D# r T7 <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection By Delc ❑ WAIVERRecelved <br /> Deffiructian Inspection B Date oasrructp Well Depth O <br /> COMMENTS ! <br /> PE SC Amount eclat! Received Permirl <br /> Codes Info Remitted B Rate ServiceR Lest# In Ice We IDN <br /> 3 ,650 3 //Qi 003 l el-78 <br /> x <br /> EHD 43.02-006 <br /> � MASTER W ATTR WELL PEAMtT <br />