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�U<�^ WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HVAW,fDEPARTMENT 600 EAST MAIN STREE1`%.0cKT0N CA 95202-(209)466-]420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-76PI FOR INSPE ONS EXPIRES 1 YEAR FROM DATE ISSUED a+' <br /> w <br /> Joe ADDRESS cdrr/L/P -4c-"'Po <br /> CROSSBTREET APN - 0 PARCELS1 LZZ5'CA7b DaEAPPUCAT # P'+_WQ <br /> OWNER NAME (, PHONE <br /> OWNER ADDRESS <br /> CONTRACTDR <br /> CONTRACTOR ADDRESS Riq F( Zme'�AFI�CZISTATEMP � . <br /> SUeCONTRAcTW PNONE <br /> SUBCONTRAC'TO`R A_nn as CITYBTATE/LP <br /> LICENSE IAC-'/ ] C-61 C 1}-0g ❑Other NUMBER E)(f4.0NDATEr—� <br /> GEOGMFHICALINEORIARTION: CcoNinates X V Township_ Range_ Section_ <br /> INTENDED Use L DomestlTlPrivas ]Imiletion/Agricultural D Industrial Water Quality Monitoring C Soil Sampling/Characterization <br /> Public Water System <br /> nd1fammft.0*o&- mters,uemmme or e <br /> TYPE OF WORN New Well n Replacement Well L Well AfteratioMAodificetion L Other <br /> M.D itoring Wells) 4o wells ❑Soil Boring(s) eMbow s L Geotechnical <br /> fY I-OPSentice Wel L Out-Or-Service Well Renewal ❑CmssConnection Repair <br /> L New Ptunp ❑Pump Replacement D Purnp Repair L Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary ❑Ak Rotary D Auger D Cable Tool I I Push Print D Other <br /> Proposed Well Depth ft Excavation in diameter C Open B.H. Gravel Peck/Gravel Size in diameter (� <br /> 1 Conductor Casing in diameter / Conductor Casing Depth <br /> Well Casing Diameter_in Thicknes&fGauge/ASTM Schetl ❑Steel ❑Plastic Stainless Steel 1 Omer <br /> Grout Seal Depth ft L Neat Cement(94 It,bag/610 gat wafer) ❑Send Cement sack mixR gal water <br /> i BenlonRe(20%solids) i i Other <br /> Grout Placement NaMod D Pumped UFree Fal LOther I Retardant I Accelerator(name) `(1„ <br /> PEDESTAL Installed By i Duffer 11,11eump Contractor 1 Omer `1 <br /> Concede Pedestal Dimension:Width_ft LengthftThick in ]Christy Bos ❑Srove Pips 1 <br /> PUMP -_Submereide❑TUlbine C Omer • HP Pump Set ft Standing Water Level ft <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE MTN SAN <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. i ALSO CERTIFY THAT MY REQUIRED LICENSE IS 1 V <br /> CURRENT AND ACTIVE WITH THE CALIF RNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL 1ry1N\ <br /> WORKERS COMPE ATION LAWS. <br /> M IM O ADVANCE NOTICEjiEpUIRED FOR INSPECTIONS <br /> SIGNED —l/ /llt 1 \ <br /> TILE DATE <br /> N (� <br /> m <br /> _ EPA RTMENT <br /> Appltudion Accepted By Date y [(-d Area Employee IDS <br /> Grout Inspection By Date SPECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Sol Boring Inspection B Date Constructed Well Depth ft <br /> iF9MMENTS <br /> PE SC Received Ch Amount new Permi 51nm1c* ;W91I;1D#Cod" into B Cash Remitted SemiceR uestM <br /> 4 178- t�fLr 8 too,EJM _�-•�- <br /> � dl '��Jr^/lP ��CC// f��P►�I� r�/.t./�C� 7✓i-t C�c7>y <br />