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WELL 1 PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH D6PAMMENT 304 E WEBER AVE Yo FL-STOCK70rf CA 95202-(209)4603420 <br />[E NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR PROM DATE ISSUED <br /> Jos ADDRESS D-21/1�(1S�d�l _ CMrzI"xyA A& <br /> 2!��J �j 6 d <br /> CROSS STREET d APN4? [7O41Q ate{ PARCELMZX 33 LAND USE LICATIONtt 7 <br /> OWNER NAME _ y'7 _ � � `k .,,,. PNON �} <br /> OWNERADDRPS.S 1 L. R►ver I CAI�IV �t�} —� C17'YISTATFILI1� CA 95,281 <br /> t <br /> CONTRACTOR C31- PNON <br /> CONTRACTOR ADDRESS <br /> I ar + CITYISTATEMP <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADORM CITYISTATL17AP <br /> LICENSE OC-57 D C-6l Q D-09 Other _ NUMBER T - EXPIRATION DATE <br /> I <br /> F GFACRAPHICAL INFORMATION,. Caardloatne X Y Township_ Range Sectiones fes. <br /> CINTENDEtrUSE 4Dornestieftvale Olrrigation/Agricultuml E3 Industrial OWaurQuality Monitoring E3 Soil Sampiing/Charaeteriation 1\` <br />+' Public Water syyyyyyem 1�- <br /> 1 IfdifU—I .Ob r. aror yrm,n ame ucr can ar ne tf <br /> [y(( OP WORIt O New Well 0 Replacement Well Cl Well Alteration/Modification 0Other 1 <br /> O Monitoring Wel](s) p of wella 0 Soil Boring(s) s sfb"Unp O Geotechnical s arbaday <br /> D Out-Of-Service Well 0 Out-Of--Service Well Renewal O Cron-Connection Repair Q <br /> O New Pum Pum R lacement --[3PUrnpRepalr 7`► <br /> WELL CONSTRUCTION <br /> Drilling Method D Mud Rotary O Air Rotary D Auger O Cable Tool D Push Point D Other <br /> Proposed Well Dcpth R Excavation in diameter D Open Bottom 0 Gravel Pack/0mvel Sim in diameter <br /> 0 Conductor Casing in diameter / Conductor Casing Depth fl <br /> Well Casing Diameter_____.in ThickneseGaugVASTM Scholl 0 Stat O plastic 0 Stainless Steel O other <br /> Grout Seal Depth R O Neat Cement(94 1b bog)J•10 gal water) 0 Send Cement sack mix 17 gel water <br /> O Bentonite(20%solids) D Manufacturer Spa%solids_% Name D Specs on File 0 Specs Submitted <br /> Grunt Placement Method O Pumped O Free Fall D Other CI Retardant)Accelerator(name) <br /> PEDESTAL Installed By O Driller 0 Pump Contractor O Other <br /> O Concrete Pedestal Dlmenslo=Width R Length ft Thick in Q Christy Box 0 Stove PI <br /> pe <br /> Puarr Submersible O Turbine D Other HP Pump Set fl Standing Water Levet A <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. 1 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 /> r <br /> WORKERS COMPENSA ON LAWS. <br /> i MINI �24H'UR AD NCE NOTICE REQUIRED FOR INSPECTIONS <br /> TrrLE DATL <br /> ' ' I <br /> f N <br /> 0 <br /> T <br /> NIB- <br /> 0 RTMENT USE ONLY e <br /> Application Accepted By to 07--10-0-47 Area Employee ID# -+0OO <br /> Grout Inspection Ef Date OMCUL Well Permit <br /> + h <br /> Pump Inspection By Date 711171'26.5 O WAIVER Received <br /> 4 Conatrocted Well Depth A <br /> COMMENTS <br /> PE SC Received Checldil Amount Permit/ <br /> Codes info B e Remitted Data Service uest 0 Invoice# well IDP <br /> 10T.15R60 <br /> F]m<S-0r-0as <br /> ' <br /> [moans WELL PUMP>rnA1R <br />