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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNFV ENVIRONMENTAL HEALTH DEPARTMENT JBCEWEBERAVEY'FL-Src ONTONCA9S2D2 .(JD9)4W312A <br /> 'NON-REFUNDABLE PERMIT CALL <br /> (209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED , <br /> JOB ADDeeee OLJJ 5 /`C-GrI CDT/2iP nx- <br /> •' m / <br /> i CROSS STRgko <br /> FT LS I �P__APN 9/.IF II L' 'J�PAPf.[L$I2E�aNDUSEAPNJCATIONM � v <br /> OWNRRNAME /70/' tea-'/ PHONE <br /> OWNER ADDRESS .3 r fe S CrtY/$TATFf/AP <br /> CONTRACTOR Ma T2 dtS P4 yNPHONE 112� /- <br /> ConTRACTORADDREaS � ' I /FiCIM1> M. CITV/STATE(LIP „r� OA0 Z���✓/ <br /> SL'RCohnr AC R FHONE <br /> SUBCONTRACTORADDRESS CITY/$TATE(Llp <br /> LICENSE 4-57 ❑C-61 ❑1-09 ❑Other NUMBE 2 EXPIRATION DAm <br /> GEOORAPHICALINFORMATION: Cmrdieafea X Y TawNh(p_ Range__ Senlbn_ <br /> IRTENDED USE DomestWPrivae ❑hrige1i1NA,1tdt I Olodumriai Cl Water Qua'Sty Monitoring O Soil SAMpling/Charecterir<Doe Q <br /> ❑Public Wale,System <br /> IIdiR(from O»ner a sone Maes amen <br /> TTPEOP WORN av Well Cl Replacement Well O well Altemt mmodifiendon O Test Hde ❑Other <br /> Cl Monitoring Well(s)__kof wells ❑Sail Boring(s) "'oes"gs OGmlahnical roreadr'p <br /> 0 W Dcammico 0Out-0f-Service Weil 0Out-0&Service Well Renevral <br /> O New purep ❑Purre,Replccc.t Cl Puree Senior ❑CmmConnsalm Rcpat 2 <br /> WELL CONSFRU��''��jj99rN+ J<! <br /> Drilling=i8Mud Rotaary�.�s OA ir Roery OA ❑Cable Tool 0Push Point OOther <br /> Praspoaed Well Oep�lh` a ExcavnUnn to diameter ❑Open Bottom ❑Gravel Pack l Gravel Six_in dismeta <br /> OCoed g in dime I Cond''ucl!tor��Caning Depth ft <br /> Well Catalog Diameter w Th¢knma/QZAS7".H Schrd- ❑Seel OtW,k ❑Stainkss Serf OOther <br /> Grout Seal Depth ft ❑Neat Cemem tW lb Aag)5-10 gal warm) ❑Sand Cement sock ode 17 gal water <br /> �Bentoni¢(20%solids) ❑Manufxoumr Spec eso1Ws_% Neme ❑Spason File ❑Spas Submitted <br /> Grow Placement Method ❑Pumped 0 F.F.11 C orhu ❑Retardant/AccelaatoT(name) <br /> PEDsrAL Insuuw By Cl D.H. Rump Contractor ❑Other <br /> O Concrete PedMtd DDoeasom; Width_R LeVh_R 'brick__in OChrbly Roe OSRve Pipe <br /> PUMP 0 Submersible ❑Totbine ❑Otha__ lip_ Pump Set_R Stabling Watt Earl fl <br /> WELL DEEraucTRIN 0Open Section ❑Omni Pack OUncurd E3 Other <br /> • Weil Diameter_in ToW Depth ft Depth w Wattt ft 0 Casing w be Perfom1nd Rom_ft w_A <br /> Soling Material O N®t Cement(94 In bag/5-10 Sol wua) O Sand Cement_sack me/7 gal wswr ❑Recitation Pellets <br /> 0 Benwnitn(20%solids) 0 Manufacture,Spa%solids % Name ❑Spem oa File O Spm Submltlbl <br /> Placement Method ❑Pumped ❑Fra Fall ❑Other_ <br /> ❑Complete with Mushroom Cap 0belcwDads O Com Icc W existing Surface Pad <br /> 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL SE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS. I 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 /> /I/SM�INIM/UUM 224 HOUR ADVANCE NOTICE REO(U/HIED FOR INSPECTIONS <br /> SIGNED G-1/t 1 P fol-aPiLO( TME �� 1[f LPI DATE <br /> A Ul <br /> { N <br /> H <br /> I <br /> EPARTMENTUSE Ni,,[LLY,(,/�1.�,/� .•s ¢ <br /> AppliemionA cepted / Detc-='?J� /� A. a+I Pm9lola lDk <br /> Grout fats ti Dnw7 ❑ SPECIAL Wall I Villlt <br /> Pumpinspah.By Oate ❑ WAIVER Received <br /> Danosdon Inswiton By Date Caattruaed Well Depth R <br /> COMMENTS <br /> PE SC I Reaivid Cha Amount Peras IRV.W# WdI1DM <br /> Cade. Ulan B Remlted LDiaia <br /> Servke Rasioestk <br /> D DL 22 D ikmg b T I PCC, <br /> EHpt}ntyr5 MAaiE0.WATER WELLPERMtT <br /> INaarNm <br />