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- / <br /> SAN JOAQUIXCOUNIy ENVIROXM I I HfA, D�ARTMWJ PUMP PERMIT <br /> � 304 E WEBER Ave Yr FL-STOCNTOX CYBBBNW2 :(209)4884420 <br /> NON-RE�P1UUNNDABLE PERMIT', T CALL(209)953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED <br /> JOB RCS4 O5 T,,tinsrm e( CRY/LIP_aZeiz II-i "A <br /> l^ P 3 <br /> CROSMSTREET L(/U APN ��' •Q`2(J of// PARCELSIM q)q <br /> OWNERNAME naerves PHONE <br /> ✓ <br /> OWNERADDRISS J CITY/STATE/ZIP �OV/ <br /> COWRA(TOR <br /> If <br /> CHNTNA(TIN Al111R � PIDXfL &16 <br /> 7 5W& <br /> CITY/SIATIf/A /Ar /A I <br /> SVW ONI'RAITOR I'llow. O <br /> SU W VNTRA(TOR ADDRE-s9 CITY/S'I'ATEJZIP <br /> LK:uIsE 0C`57 ❑C--01 ❑D-W ❑Other NUMBER. EXPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y TDWnaMp Itsm,_ Beed.._ V I <br /> )NTCNDED Us[ ODomestic?rivuc_ 1w,ngwmNAgricRhural 0Indusmal „ owtun Quality Memnon.' O Soil Sampling(Chayaderiati9n <br /> dPublic Walc S , � I _.� .. . . <br /> m <br /> Ifd,ff. on <br /> a Ysnm ane on onRm m u <br /> TYPE OF WORN ❑New Well OReplecemsl Well ❑Well Alteration/Modification ❑Tem Hole OOlher Z' <br /> num oPuellr numbsolbonn <br /> ❑Monitonn8 Wells)_ ❑Soil Baringfs)�_ ® O Geotahnicnl n,.,8a nrhndnM <br /> O Well Destruction ❑out-or Service Well Cl Out-0fScrvice Well Renewal <br /> New Peorp ❑Pum Replacroo,vt O Pum ft air O CnvoCcmneaimt Re it <br /> WELLCONSTRUCTron <br /> Drilling Method O Mud Rotary O Air Raw, O Auger Cl Cable Tool O Pu.h Point ❑Other <br /> Proposed Well Depth R Excavation in diameter, O Open Domain O Grovel Pack/Gravel Sia iri diameor <br /> OCemductur Casing indinsler / Cmpduclor Casing Depth n <br /> Well Caring Diumrar_in ThickssNGaugc/ASTM Schrd O Strel O Plastic O Stainless Steel 0 Later <br /> Grout Seal Depth It O Not Cement(94/h hole/5-10md mrier) 13 Sand Cement_ xnrkmh/7 Rol wnn <br /> O 9cnumor(20!%.vlid.) O Munul'swrcr Spa%wliJr_"G Non.: OSpccsun Filc OSpce.Submined <br /> Grout Plovemem Method O Pumped O F'rea Fall OOlhcr O gelmd. l/Accelc Mm(move) <br /> PEDES Al- 1.11.110 8, ❑Driller ❑Pump Contractor ❑Olhn <br /> O Concrete Pedestal Dimen.lom: Width_ n Lcnglh R Thick in 13 Christy Box ❑Stove Plpe <br /> Purge Submersible ❑Turbine OOlher HP Pump Set R Standing Water Level R <br /> WELL DFSI'RUCr10N ❑Open Bottom Cl Gravel Pack ❑U...x Cl Other <br /> Well Diameter m Total Depth n Depth to Water n O Caning o be Pcationded from_R to D <br /> Sealing Material Cl Neat Cement(94 IA hog/5-l0gal nerr) ❑Sand Cement suck mir/7 Wal water O Bemonile Pcllcu, <br /> O Bentonne(209*solids) ❑Manufoctumr Spcc%wlid. % Namc O Spins on Filc O Spas Submilled <br /> Pincement Method O Pumped ❑Fra Fall ❑Other _ <br /> ClComplete with Mushroom 6, R blow <br /> , grade - Cl Complete to Exiating Surface Pad <br /> 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACQORDANCE 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 /> MINIMUM =4H VANCE NOTICE REQUIRED FOR INS CTIONS EASE CALL(209)953-7697 <br /> SIGNED TITL DATE <br /> NLojN <br /> PULIC E <br /> IC <br /> J� /M// DEPARTMENT ONLY <br /> Application Accepted By AV-16-03 <br /> �LreY aDole V_[! 03 Area c7/,Z Employs lDN _j-366 <br /> Grout Inspation Derr 13 SPECIAL Well Permit <br /> Pump Inspnti By Dal�ir') .Z ❑ WAIVER Received <br /> Deswmi.n Inspatian By Dam Construdetl Well Depth n <br /> COMMENTS <br /> PE SC Received heclul/ Amount Dale PcrmlU Involeep Wall IDN <br /> Cade. Info By Remitted Dole uestM <br /> oo to S' OD�� I 7 <br /> END d7-02JIOh MASTER WATER WELL PERMIT <br />