Laserfiche WebLink
c % WELL if PUMP PERMIT <br /> SAN JOAQUIN CMilTY ENVIRON AL H[ALTH DEPARDRDTE 3(10EWEgCRANE3e FL-STx ErMCA95202 - (209),16&3420 <br /> NON-REPUNDAB IT• CALL(209)951.7697 FOR INSPECTIONS EXPIRES 1 YEAR F -ISSUED <br /> _ v <br /> _ _ 1 a <br /> JW <br /> CMZP <br /> C .�1 / 'r// PAIICELSru //•'t//, IASL AMLIUT.S I <br /> IF <br /> It" NAME q1 ^ IMONEE� qq ` <br /> OWN w ADDRSa .v— ® CMISTATEMP tAFLJOP `t� I <br /> TAmmALTOR Vda MOnE 4/z1-/r/:2_Siz <br /> CONT4CTOR ADDRCST CM/STATNAP�J�d C/V!J <br /> SIIH.'OnTRAROR MOHL <br /> SUBCONTRACTOR ADDRESS CMISTATE7AP <br /> LICENSE 6011- 9c'$1 ❑D49 O tither NUMBER Ema.I an DATE -� <br /> GEAKR MI LINMRMAi1dH: Caurdirrams X Y T9wDaMp_ Rage_ Seetba_ <br /> InTLNOCD USE O DomatirlPrivam O IrriptiONAgriCuln O IMuuiM O Witter ality Menibnn0 1 O Soil Sme sh.,1Chvncmria4on <br /> (Public WamrS stem � 0./ Aa . l� j 1� S=']o Ow <br /> IIdiff fin n TT b�17— n ^R^�Tx�e <br /> TMOPWORK ONew Well Cl Replacement Well ❑Well AltemionlModification ❑Teat Hol. Cl Other <br /> O Monitoring Wdl(s)_Mof wells OSoil BorinS(a) xolbenM 0Gmtahnin1 xareMp <br /> O Well Destmetlm D Out-OfAmice Well ❑OutOfSeMce Well fa,d.l <br /> New <br /> Pump ❑Pinnp Replaceenent O P..p Repair O G nss owl ation Repair <br /> Will CDNTrR4C rK)N . <br /> Drilling Method CI Mud Ronny O Air Ronny ❑Auger ❑Cable Trot ❑Plah Pomt O Olbm <br /> Proposed Well Depth R Excavation in diameter D Open Boilers O Grovel pack/Gravel Six in dia,was <br /> OCoeducta Cwmg; .diamNer / Cand.to,Cai.,D tb 0 <br /> Well Ca ing Diameter_is Th(ek;i a/GaugdASTM SchcxlO Smel ❑PIu4c O Swelas Steel O Other <br /> Croat Sal Depth ft ❑Nat Cement(P4/h hag/3-10 gal KOW) ` OSAWC.1 sxt MS/]gal unto N1 <br /> O Percentile(2(MA solids) 0M. &,tuner Spa%solida_% Name O Spam on Fik O Spea Submitted N <br /> Grovn Pinnae.'Method ❑Pumped OF—Fill ❑Onher ❑Rmatdaret/Acceknmr(oam.) - (A <br /> PEDESrAL I.M.IIM By ❑Driller mpump Conimew ❑Olber <br /> Cancrele Pedesnl Dilatations: Width 3 fl tnn th fl+r Thick in ❑Chrlky Bax OSave Pipe <br /> MBD Submemible ❑Turbine ❑Olber HP/,y Pump Set fl SHndi,%Wetal.evel jj2e A <br /> WELL DESTRUCTION Cl OW Bonmt E3 Gravel Pack ❑Unceaed ❑Other <br /> Well Dn sna r in Tom]Depth R Depth m Wattr ft O Casing m be Pafonted fmm R in_It <br /> Sealing Material O NatCana1(94/A hog/3-10 gal wle�J O Sand Cares, sock Ma 17 gal water O Beensaine Pellets <br /> O Bentanite(20%aoI,ds) O Manufacturer Spa%solids_% None ___ O Spas on File O Spe a SubmilMO <br /> Placement Mabod O Pumped ❑Free Fall 13 Other <br /> O Complde wiM Musb. R below grade O Complete In ExiMing Surface Pad <br /> 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK SS'11.L BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS I ALSO CERTIFY THAT MY REQUIRED LICENSE IS en <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL ep <br /> WORKERS COMPENSATION LAWS. <br /> MI UM 21 R ADVANCE NOTICE Q[iQUED FOR INSPECTIONS <br /> BICNED TITIE tees DATE <br /> ull <br /> DEPARTMENT USE ONLY <br /> Application An epted By - Date A. Empbya 1Dg 5366 %9 <br /> Grain trupadrn By Date O SPECIAL Well Permft <br /> pump 4mpstian By Dam ❑ WAIvER RRdeived <br /> Dnwctson hil ctbn By Dam CovMrOcted Wag Delta R <br /> COMMENTS --_ <br /> PE SC ReaalradAmount Data PermW Inr�kaa Well IDM <br /> Codex let. B ab eminod ServkeR wM0 <br /> aha aim <br /> -m , b Ol <br /> 43 osr61 1 <br /> r <br />