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\\o�� WELL/PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304E WEBER AVE 3"FL-STOCATON CA 95202 -(209)""470 NON-REPUNDABLE PERMIT CALL(209)951-7697 OR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED 7 T JOBADDRESS / C V Cm2R -TZ,J4GY 9SiQl � '"4/' a CROSS STREET RL�{ZCf AI 1Zx.AU APN Z09-036-OS PARCEL$ITE 3 -(fLANDUS[APPMCATIONM p OMTIPR NAME -7ZAIA99 C4JVUV'AAIf TIE; PRONE ZOq-E36-15;4'r OWNERADDRESS /1� l3LtJD.j 51,1 rL-A- CRYISTATFJZIP 7IJALl CJr 95 37A CO`THAcTOR i�JA)I FA rel f e1 A'JI far,/¢C `A K_. !PHONE �:I'/L�,{�-T-(IS�I�/_� CQNTRACTORADDRESS')/yg FLANC WJSST C_f r/-Fy 5,411rZe L' C 1rYfSTATVLP .5-TOEIS7pAjJ r_-T -7524ka SunconmBAcTOR -SIytLTK[I19Ax 1:-::,X)lt1eAM1nA/ PHONE SURI:ONTRACTORADDRISS Z3f,5 LI+JQLLIAm be, CITY/SrATE21P;'A.EJ('TOA/IC}} 95299 LICENSE C-57 OC-61 13 D-09 ❑Otho NUMBER S/22 EXHRATIONDATE O GEDORAPmCALIHFORMATION: Caordlnatm % V TOWas tp / .5 Range&L-a- SMlbn-,t INTENDED USE ❑Dameaxc/Pfinte O 11rigniosUAgriculturel 13 Industrial tn'akr Quality Monitoring O Soil SamplinglCharseterintion (3 Public WaterSynteQ UE,aertur V Wee Wirers me ltlm .mseamoral M um TrnE Or•WORK ¢(New Well ❑Replatcreent Well O Wall Altuntion/Modifiution 13 Test Hole 13 Other \J) AMonitering Well(e) 'VM ofwa))s ❑Sal DoAng(s) aureudnm ❑Geotechnical a.fbenda O Well Desuoclion Cl Out.04Service Well ❑Out-0f-Service Well Renewal O New Pump ❑Pump Repism,carent O Pmp Repair O Cruse-Connection Repair WELL CONSTRU17TION Drilling Method ❑Mud gantry ❑Air Salary Auger ❑Cable Tool CI push Point 13 Other Proposed Well Depth 121 t Z5 f ft Excavation in diatoms ❑Open Bottom O Gmvel Pack IGravel Size in dissMer ❑Conductor Cuing in tliamekr I Conductor Cuing Depth It Well Casing Dlamaa 2J1 in ThicknadGaugdASTM Schad 40 ❑ST-TW.--O- 13 Swifflear Steel DOIhu Grout Seal Depth4D74'd Q-JJ ft XNW Cemrnt 04 th bog/5-10gu/water) ❑Sand Cement Taekeral-Isalwsta ❑Domain,f20%Solids) OManufacmF:r Spec%solids % Name_ OSpecson Fik OSpecs Submitted j Grout Plate..(Method Pumped ec Fall OOtha O Retardant/Aecelerator(name) PEDESTAL Installed ev XDdller E3 Pump Contractor E3 Other AConerete Pedestal Dimenslm: Width.. ft Lenglhti ' ft ThickZL in OChrlagq Rmx Xsereepl, PUMP ❑Submersible ❑Turbine OOther HP__ Pump Set_ft Sanding Waa Level ft WELL DESTRUMON ❑(Igen Bottom ❑Usual Pack ❑Untanned ❑Other Well Diameter_in Tani Deph ft Depth ieWatts ft O Casing io be Perfmu:l tram_ft to__ft Sealing Material O Neat Ccment(9416 beg/1-10S.?wored C!Sand Cement .,.k aixl 7 gal water ❑Bentonite Pellets O Denmam(20%sulids) O Manufacturer Spec Su solids % Name OSpanon File ❑Spas Submitted Macerator Method ❑Pumped O Free Fall O Other_ O Complete with Mushroom Cap R be.grade O Consulate m Existing Surface Ad 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND RECULAT'IONS. I ALSO CERTIFY THAT MY REQUIRED L CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCET NT WORKERS COMPENSATION LAWS. IN MUM 24 HOUR ADVANCE NOTICE REQUI/RED FOR INSPECTIONS Q('{Iy /v� SICN¢D .� R:(��tdJMIG,F1va17ttu. TITLE t: DATE .g�i0_0 G112QQ4 (a \ ry . Nr JS d \ t1 \ nim t DEPARTMENTU E N of Application Atcepled By irDan, - Arra f. Employee lDp Grant Inspection By Date_ 1 ([ ❑ SPECIAL Well Permit Pump laspatian By IMI. ❑ WAIVER Received Destruction lruymisn By Data Constructed Well Depot It COMM TSF MW H .aLxA/JJ•( y S IYNR•ia' lA.A:.•AI Cart: 1wu !4y •1 J J 1 ' A [r .4E 1' 41 i Z ..-xffa�le PE SC dwd vU' at Amount ermW D h le lever Well Him,Cedev Info B ash Remitted ServkaR neap � I ar- i