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SAN JOAQUIN COUMY ENVIRONMENTAL HEALTH DEPARTMENT 304E WEBER AVE 3"PL-STOCRTO rM 1O <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR UE <br /> L � h <br /> JOB ADORPSE /fid Lit, R,��)_ �jcrrv)yzwp ���A [A y <br /> �Pf�f�(IR/B 1 C n <br /> C0.0BE STREET (J�/♦'/�Ir,�-. ppry PARCEI.SIZE �•-+ Pp° <br /> OwNERNAME /K//`I1J['A/' .M�V�••'r'� Piton <br /> ' OWNERADIIRFSS , (/�� CTIY/STATFJZIP <br /> CONTMLTOR N 1/[fS•S� K/I�I L / PNONE 311i�-7 -5 <br /> CONTRAG-I'ORAnDRES3 W �I C11Y/SfATEJZIP� k+ CJi L t1 AJ�7 O <br /> ' SUINEDWRACTUR �/n_.�T PUONE-7 SSS�"�"7` �Q •� <br /> SosvohiTRACTORADDRRSS CITY/STATE/ZIP AL� /S�j04 <br /> LICENsfi C-57 0C-61 OD-09 13 Other NUMBER 8S Explmnohi DATEj� <br /> GROGMMII[AL INFORMATION: Coorclastee X Y Township_ Range_ Seell <br /> IMENDED USE *ArDomulic/Private O lrrigation/Agnomlonal ❑Industrial O Water QMlity MWitcring 0 w SamplinP/CheT+otetiTation <br /> O Public WaHxSySNxn <br /> RGRenns Oam tw: . .Nemo norm mrcw um <br /> ' TWEOFWORK,WNeW Well ❑Repiacemad Well ❑Well AltetatioNModiScation Cl Too Hole 0Other <br /> O Monitoring Well(s) �.F.dh C3 Soil Boring(s)_ nor1`a(bonv ❑Cmelcchnical a�ama,aruWmP <br /> 0 Well Destruction D Out.OfService Well ❑Out-Of Semce Well Renewal <br /> dew PusnD 0 Pump ReelaeemWt 0 Poore Repair ❑Cross-Conner ion Repair <br /> ' WRU.COFesma T i <br /> D,ming Method Mud Rotary ❑Air Rotary 0 Auger ❑Cable Tcol 0 Push Psin, 13 Other <br /> Proposed Weil Depth� ft Excavodmt in dvmeter D Open Borbm Grovel Peck/Gtavel Siu in dianux:r <br /> O Cenducror Cuing in dxrneter / Coad MC,si Depth fl <br /> ' Weft Casing Dia.,cr�in TTickness/GaugrJASTM Schell l 0 Stml b.Tlnsde 0 S ainka Sceel D Other <br /> Groutseal Deptll CQ _d ¢$vnd CNned .WAkmk/7gelwata <br /> 0 Bentonite(20y.Solids) ❑Maoufaeturcr Spec%Solids_% Now O Specs on File 0 Spee Submitted <br /> Groot Plaeaareathf.bod .ped OF.F.11 DOlber ❑Reurdant/Aeedc000r(opne) <br /> PEDESTAL Installed Bo to (3 Fu <br /> Q OGha <br /> O Concrete Pedestal DltWosioBe: Width fl Length C 0 Thk in OChrlsty Box OSmve Pipo <br /> PUMP "Submersible OTWbine ❑Otho HP_S-- Pump Sel_R ShMing Water Level N <br /> WLLLIEETRDCTION 0Opee emlan 0Gmvel Pack 13Umxsed ❑Other <br /> ' Well Diarnaer__in Total Depth R DgNh m Water D O Casing w he Pertoracd from__-ft to__-ft <br /> Sedhrg Mswhd 0 Neat Cement(94 th hogJS-IO bot waver) 0 Sand Cement snrk mux 17 gal Water 0 Bentonite POW <br /> ❑Benronim(20%mild$) OManufacvwer Spec%solids_% Name ❑Speson File OSpwsSubndued <br /> Placement Medeod OPumped E3 Free Fall 0Other <br /> ' O Campleve With Mushroom Cap itbelow Brale O Complete a Existing Surface Pad <br /> I HEREBY CERTIFY THAT 1 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 MV REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LWENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> NIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> $N:NED TITLE CX / � DATE:-- S—O <br /> - LL 1 441 12 <br /> ' s DEPARTMENT UONLN, <br /> � <br /> Appticadon Accepted By Dere ? OL Area 2-12-- EmployeelDB.L�.L.]_ <br /> t Grout lnspectior,BY Dare _ 13SPECIAL Well Permit <br /> Pump to"hou By Dare �� ❑ WAIVERReceived <br /> Destruction IMpeclion By Date Condrucled Well Depth_ R <br /> r <br /> COMMENTS <br /> ' c 'U2- <br /> PE SC A tort B�v� Dale Invoice# WeII ID# <br /> Cadet lofo Remitted BY- ScrvittR uesnB <br /> W D a, <br /> ' <br /> WNYJF <br /> oLOU&044c013 <br /> EHD 43A2-0D6 MATTER WATER WELL PERMIT <br /> 5/7200. <br />