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WEW PUMP VERMrr' <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTII DEPARTMENT 304 E WE.BRRAVE 3°P FL-SMCKTON CA 95202-(209)46&3420 1 <br /> NON-REFUNDABLE <br /> +PERMIT' / CALL 209 953-7697 FOR INSPECTIONS EX/PIRES/I YEAR FROM DDATE ISSUED � <br /> in <br /> JOB AD¢ UPE55. rJ t/t/ ..I A� . �f'�t�- r..,[�/ Ctn'21P. i�CIQ�- E=-G. l "162 FA <br /> �. o <br /> CRUBS STREET % e? /rl APN���OYy_"a PARCELSIZE <br /> 0NNERNAMEr—UpPe <br /> /� QN O RCA VlC /q�JJ �P/RONE� �2- /J ,ems-• <br /> OWNERADDRESS _fi'OO r FIn .� Z&1,'. J 41 CiTY/SI-AT!rZIP.%✓1lk% TSZ/.J <br /> ` <br /> CONTRACTOR rr G J'.A.1 L�t N /,,N�O,/NE <br /> l 1 8 l be a ur 4 CDY/SYATTIZIP we -,! 0 r� <br /> CONTRACTOR ADDRESS T <br /> I <br /> SUBCONTRACTOR PIIONE <br /> SUBCOWRACTOR ADDRESS CrrWSTATVZIP �}�.� <br /> LICENSE C-57 C3 C,51 OD-09 ❑Oche! NUMBER -Aar-- EKPINATIONDATrkj / � <br /> CEDORAPHICALINFORMATION: CoordlmUJ X Y Township_ Runge_ Section_ <br /> INTENDED USE 0Domestic/Private O lrtigation/Agriculluml Olndustdd ❑Water Quality Monitoring .11�� ❑Soil Sunpling/Chmeatanaadon <br /> ypt,Public Waters tem t. kalroa % rA % bJN !. $ ylrM CY 15.1"^-/ J���a'Ot�Z�o <br /> 4` hotlRren,h°miyan.r: ' awr rwm as <br /> rah ° <br /> TVPEOF WORK 0 New Well 0 Replacement Well 0 Well Alteration/Mdiflenton 0 Tat Hole Other A. <br /> O Monitoring Well(s) ^.neo.r.enr 0$.it Bedng(s)_ O°1Oa°`OraOfj°s' ❑Owtahnieal ,rvn,ber of bwinp <br /> 0 Well Destruction 0Ou-OF-Servlae Well ❑Om-OFSmice Well Renewal <br /> 0 New P..p ❑Pump Re lacempnt 0 Pum Repair 0 Crass-Connection Repair <br /> ELL COMSUCTraIdgnsa <br /> Drilling Method Xud Rotary 0Air Rotary 0Auger`s OCable Tool 0Push Point 0011151 <br /> Proposed Well Depth, ?W EacavMion�_in diameter OOpen BDltom ,,1,WveIPack/GmveISi=.indnmmer <br /> OConduct a;mg indianwter / Condueror CeaUZ Depth R <br /> Well Cuing Diamenr in ThieknesNCauge/ASTM Schur 00 OSteel WNestio ❑Slimes,Steel 0Other U <br /> Crmrt Seal Depth- R ❑Neat Cement(9gthhug/3-logo/water) 'Sand Certain /�Jr 27 .ton*m1A 17 gal waw <br /> foTi¢�p6»Iiia}— O M...Acturer Spea%solids_% Name ❑Specson Fik ❑Specs Submitted <br /> Grout Pluemenl Method umpd ❑Fre<Fall ❑Other ORCInNan/Accelennor(no=) <br /> EDESI'AL Installed By C3 Driller ��mp Connector OOther <br /> Conbrem Pedolal Dimensions: Width R Length R Thick in 13ChIlIty Boa ❑Stove Pipe <br /> PUMP ❑Submersible ❑Turbine DOther. HP Pump Set R Standing Water Level R <br /> WELL DESTRUCTION 0 Open Bottom 0 Gravel Pack ❑Uncued-- O 0t1w <br /> Well Diameter in Total Depth R Depth to Waw II 0 Casing to be Perfantd rum_R to R <br /> Sealing Material ONe+t Cemenl(94 lb fxrj;/5-IOgu(wrrterJ ❑Sand Cement sock mla/7 gal water O Bentonite Pellets <br /> O Bentonive(20%Solids) 0Manulhcnw Spec%solids_% Name OSpeeton File ❑Specs Subttiped <br /> Piaeemeat Method ❑Pumpd .. 0 Free Fall ❑Other <br /> 0 Complm with Mushroom Cap it below grade Cl Complete to Existing Surface Ped <br /> 1 HEREBY CERTIFY THAT I 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 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 /> 1 MINIM//J/7.24 HOUR ADVANCE NOTICE RE�UIRED FOR INSPECTIONS <br /> SIGNED�/ I 1 r ^l av,IAM TITLE��.�(�!c N DArE <br /> F \ <br /> it <br /> tit <br /> t a <br /> 0 <br /> PIH <br /> EM'IPONht_.v �.,/ DEPARTMENT USE N 3 <br /> Application Aecept By�Y�fC ,)' / /.l>'L� Dale 07 Area Employee IDp <br /> Oraut Inspwtion By _ Date ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVERRecelved <br /> Destruction Inspection By Date Constructed Well Depth O <br /> COMMENTS <br /> PE SC Amount echg Receives Date Permitt Invoiceg Well ION <br /> C°dn Info Remised ev Servke Re uut 0 <br /> v3 IR1 4 7 ;G- aG " r 1203265V2-70R . <br /> ElID 43.02-006 MASTER WATER WELL PERMIT <br /> 5I7ROO2 <br /> I <br />