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Ny) WELUPUMP PERMIT <br /> SANJOADOIN CouN ENVIRONMENTAL HMN DEPARTMENT E00 EAST MAY STRERT-ST KTON CA 95202-(209)4683420 <br /> NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES T YEAR FROM DATE ISSUED <br /> Jae AooREas `x$53 S✓. /?/hV 1}/EY go. aTyrzr fi¢EA�cN C�/fP 9523/ g <br /> CROSSSTREET I"1l{{II//H��'��—&eA.w1O p� –APP14J13•Zoo-ot. PARCEL SEE��O_39LANO USE APPL"TIONN <br /> OWNER NAME ((X636H 1.AW A *eper LCG PHONE <br /> OWMERAppRE9A P.O. WF 1449CMISTA rLP ft4EL7W �CTAA01 1-* 95231 <br /> Caerescros 1X1 L D AAI. XJ'-�l�r ASSOC.I JAY— PHONE Lam!-36 T•39'cl( <br /> CDNmAa ADtNHese 402 /A1/JLCSTtL4L U14H CITY(STATEILr CO til 95246 <br /> SDeCONTRADTOR PHONE <br /> Suaco arORAoomm //C_ITWSTA''TT^WZW <br /> LICENSE C-57 ❑C-S! J 0-09 C Other NDMeER IL /N 4 EMMTOH DALE 09 <br /> GEoaaAPHI INFORMATIDN: Coordlmda X Y TowMNp_ Renti Section_ <br /> INrEHOEOUM =OWNWP(We ❑Irdgstion/AgriculWmI J Ilduslfel =Water Quality MDnituing Shc SaMrAmVChalaCterinew <br /> C Publicet.Sy�m �mNl N..& ems <br /> TM OF WORN 7 New Well J Replacement Well C Well Other <br /> ]Monitoring Wells) PDf MllS )(Soil Boling(S)42//— tier mnryP :]GeosChniCal xmemia. <br /> Out-0f-Sarvlce well COut-0f-6elvi ewelilleramal =Cross-Connection Repair <br /> J New P.mP C Pump Replaosment C Pump Repair <br /> Weu awemucnca <br /> Drilling Method L Mud Rotary C Alt Rotary XAugur L Cable Tool - Push Point _ Oil" <br /> Proposed Well Depth S-40 R ESWvaOon In diameter Open Bodttn -Gravel Pad uGmvel Size N dlameler <br /> C Conduclar Casing in diameter f Conductor Casing Depth _I <br /> Well Casino Ofametar_in ThicimessfGauge/ASTM SUred _Steel Z PlesdC Stainless Steef C Omer l.+ <br /> Grout Seal Depth fl CNsat Cement(94 16 bawS.10 gel water) -Sand Cement sack,* 77 gat water <br /> y Banto61a(20%Sol ids) C 011ier/F ND b lV.r &0y4 Ca7T,9—c <br /> Grout PtaCeteMt Method J Pumped Free Fall ' Other L Retardant l As Iarator(name) Z <br /> PEDESTAL Installed By -Driller G Pump Connector C Other <br /> D Conersta Pedestal Dimensiam Wie th R LengV) ftThidl_In l Christy Bos C Siwe Pipe <br /> PuuP C SubmarslbleC Turbine '1 Other HF Pump Set R SWnolnp Watar Level R <br /> 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN m <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 I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. 'k <br /> IMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> SIGNED TITLE Pm,�GT S_<1</.U6U DATE <br /> l <br /> • <br /> I Ji <br /> Lo+ • L • wr a NTY <br /> OCL L <br /> P T ENT <br /> D—EPARTMENT UAE ONLY too7 / <br /> gpplk��a�W.jnPcoeptedey �"'� Date �--FD� Area Emplo,ea <br /> 6roDC spectian .1 Data ❑ SPECIAL Well Permit <br /> Pump Inspection By Date 7 WAIVER Received <br /> Sail Boring Inspection By Date Constructed Well Depth N <br /> COMMENTS :7m. Ze4WAQ1! .W ' /.i dW6Data <br /> xu-y76 .(/5ry/•✓ - .:4 <br /> PE SC RawMd Amaurd <br /> Codec Ilda B sh Remiltetl Barrios uwfe ImolpR Well IDR <br /> -4 7 71-7-3 <br /> END r9ae 5 WELL4HdPPFNLe1 <br /> Vllai <br />