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I AUG.21.2003 3:13PM TREAD$--:LL & ROLLO NO.087 P.5 EI,I, 1 PUMP PRRMIT n; SA14 JOAQUIN Cotrrrrr Xpvtl(ortm>Lrrt•At.UrAt vil DXrI Wf) VNT ]fl4 E Wrnalt AYa13u` I.-99`OGXTON CA 962D2 - (209)46W420 NON-RFI't1NDAltL1E PrRI►lI'r ALI. xU9 9 3- fi97 FOR I liPECTIONw 5 EXPIRES 1 Yrtnx rnio DAYL ISSUED €. foBAnnrt[ss VON So5� r:rj gzAp f3a0 F' f ra. C1Tr/Zip _ --t2ACY gS3p5� tD r M �Fm. 6 f Y. c� CROs SI.1ti ET Sfi� ARAy GAPI4 rr fl " i- OWNER rt,,nZ �F p I-- p. C 4'C • 6 S � ' o.f�' P.O. OwNERADDRES-5 SSIC O,gHaL)Sr pR4VE 1 50 ITE 2.6a S AJ AlF-Go C,4 C?2.'ZI cdA%wj.TAA1 rc�( 9iF61r gestra e(t Anatta�s S 1 Tu ST., Tfrd PG.. Crrr/SsATslztr n A w&* �0 E t+w PHONE 460_ySD_ BSL o -4 SUBCONTRACTO.. Suncoa�TaACTOR AnDR$i4S lF" . D 7 rJ � � Cl t'Y15'rA t81Zif S� `7►•s • t:,/6, '►57rx "f84xaB ° 3 Llcarisiv dl C-57 G 0.61 Q DA9 fl Other N1fMB1iR LSPtgAT't"DAT Gz0=ApRICALINFoRMA740N: Coordinates X X TaWnsitip Rttage�_ 5ecdan • flv7•I{I"t zD Un Q Dotncstitlhiyate Q InigatiWA00ultural ❑Industrial 13 Water Quality Monitoring A($Oil SampliA&Chati CW11aati4a ❑Public Watcr Systcma s� y,r lfditfaenthamOwner eter y►tant oma TYpx Or WORK Cl New Well Cl Replacement Well Q Well Altefation/Moditiication Q Teat bole Q Other r � � number ofwdls samba•4f b0 P oeeoteehaica 12-Q Mottitorin�Wei](a) 13 Soil Boring(e) � � 0 Well Destruction ❑Out-Of-Sotvicc Well Q Ovt-0f-Service Well Reacwa�r�'� CA44 Aen101V' fief � 13 New Pum Q Re lacament Q Re air Q Ckoss4onnection it r d S _ �., WrILLCON¢TAUCnON f" 17- r—FrZ s Drillivity Method Q Mud Rotary ❑Air notary a Auger l7 Cable Tool Cl Push point N Other 1 z- T 1 Proposed Well Depth. R Excavation - _ _ its diameter Q Open Bottom ❑Gravel pttok! ire in diamcler p A Caudtictor CWng�,- in dittroeter ! CDnduator Casing Daplh -- - RC9 Well Casing Digmoter_in Thiekneas/GaugelA5TM Schcd '�, 0 Stool Cl Plastic O 5t�irtlass Steal 0 � Grout Seal Depth R Q Naat Comant(94 lb bag 15.10 gar water) Cl Sand Cemcat Jack gtis 11 gal Ater x Cl Bcatonite MYagli0jr) 17 Mandaaturer Spec%solids % Nsme Q Spoon ort rilo l:l Spew Submitted ic Grout Placegt of Method Q Primped QFlooFall C1 Other ❑Retsudsnst 1 Acceleretor(name) 1 p>cSru Installed IIsWriller C]Pomp Conwactor Q Other, 13 Concrete Pedestal Dimensions: Width R Lcngdt ft Thick in Q Christy Hos O Stove Pi puMr 13 Submeraile 10 Turbine 13 Other IIP Pump Sct ft 8ttas*3in$Water Level „�R W1Lt.t.DFsTRuC71ON Q Open Bottom O Gravel Pack la Unca" Q Olber Well Digmetor in Total Depth A Depth in Water ft rl Coah►g to be Perforated from R to A f, Scatinc Material CA Neat Cetera(94 lb bag 15-10 gal warcr) ❑Sand Cement rack mtxl 7 gal water ❑Bentonite Pelku S R Bcntonitn(20y aolids) • to Manutheturer Spon%solids % Name Cl Speca nn mic 0 Speen Sub pitted Placement Method ❑Pumped Kk'tcc 17411 M other E3 Complow with Muahroam Ca ft hclew gmdc 13 Complete to ExisThi SurLteo Pad I IIRl?$RY L-gRTIFy TIIAT I HAVE, PREPARED TMS APPLICATION AND THAT THE WORK WnY j,DR DONZ IN AMORDANCE WTr'H SAN iOAQMN COUNTY ORDINAriCM ST)LTE LAWS• AND RULrtS.A" REGULATIONS. I ALSO CERTJYY THAT MY RXQtlM l UCMSZ IS CURRENT AND ACTIVE WPPB TM CALWORKIA COKMACTORS STA'I'R LICENSE BOARD AND THAT I AM IN COMPLIANCV,WITR ALL WORXV-RS COM7E1jSATI0N LAWS. MUqIMUM 24 HOUR ADVANCE NOTICE' QUMED FOR XXSFRCT10N6 SIGNRD T %B 1 � A AL gig All I Sr a e r 1 Al I TAT I I D 1 O uc K�tivt DEPARTMENT USE ONLY Application Accepted By �1 ' '' Date � ).1� L.3 Area �- �� Employee IDI! � Grout Inspection By Date ❑ SPECIAL WCII Permit Pump Inspection By Date ❑ WAIVER Received Destruction Inspection By Date Z�D Constructed Well Depth rt COMMENTS 2no.r - PE SC Xmount Chec Received Permit! ------ Date Invoice b Well IDH i Codes Info Remilled Cash ny Service Request a 3.7.2 1,y 0 230 04157SG d k C 1-0 C11D 45-02-006MASTEK W/0- It Wm. Irl.(MIT 5n/2002 '4 I