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WELL/PUMP PERMIT SAN JOAQVIN CQUNTV ENVIRONMENTAL%.,TN DEPARTMENT 381 E WEBER AVE 3-*.0koCK(ON CA%21C -(209)469-3420 NON-REFUNDABLE PERMIT CALL(209)95}76697 FOR INSPECTIONS EXPIRES EXPIRES1R FROM DATE ISSUED JOADDRSSialCTalp 'Vo / "71U, - C16' 1 p CROSSSNEET AM OXq-01C)0-0' PABL � OWNER NAME R1A2-t i _ PHONE OWNEa ADORcss Cm/STATE./TJP I CENTRA(TOR PHONE CONTRACTOR ADDRESS CITY/STATE/ZIP SUBCONTRACTOR M41A I/ PHQNE 90BCONTRAC��TO��R ADDRESS ,Q CITYISTATF/LP C• 9S .^ LICENSE 93C-57 61 0D-09 ❑Other NUMBER EXPIMTwml)ATE GEQDMPHIC.LwsDRMAMN: CeRrmnataa X Y T".Wp Range_ Seelbo_ tNTENBce USE Ommesdc/Pnwae ❑IrngetioNAgriculmnl ❑.Iendus�tri�al.�- ❑WaW Quality Monitoring 13 Soil Sampling/ChaHc[erixalion &Public Water Sntan a �R.�i./ un or Ifd@Hd rnn D. Tv,c OF WORK ❑New Well ❑Replxemem Well ❑Well AlwatioNMediOadon ❑T.Hole ❑Oda ❑Monitoring Well(s) -eba1 a.dla 13 Sell Bodng(S) ...efEeriai, ❑Geotxhnial 110"teN� O ❑Wall Deeuuctian ❑Out-0f-Service Well ❑Om,Of-Scrvmc Well Rene L Q ❑New ftnip ❑Pump Replacement ❑P.p Rqi, ❑CmssCan metice Ratiaer (w`� WELLCONSTRUCOON Dilliug Method ❑Mud Rotary ❑Air Rotary ❑Auger ❑Cable Toa] ❑Push Point ❑Other Proposed Wed Depen A Excavation in diaeumr ❑Open ONtom ❑On.el Pack/Gravel Siae indiamuer ❑C.e[ucmr Casing edia.ue- / Condoetor Casing Depth R Well Caaing D...,_i. Thicknesa/G.,clASTM Schell ❑smel ❑Pleaic O sminlm Sped OOd., G,oul Seal Dcgh R 13 Hein Coment(94 lh hay/5-10gN water) (3 Sam Cement .emk mu 17 gel wets ❑Bentonite(2004 solids) ❑Miewli rarer Spa.solids_% Name ❑Specs on File ❑Sped Submitted Gime,Placemen,Method ❑Pumped ❑Free Fall ❑Other ❑RNardaN/Atcekrnor(name) PEDESTAL 1.0.1w By ❑Duller ❑Pump Coeuaew ❑Oahe, 1 (� ❑CPacrtle PedesMl Dinansla.,: Width_ft Length n Thick in ❑ChNsty Bax ❑Sbvw Pipe 7e`y Pump ❑Submersible ❑Turbine ❑Other HP Pump Set__R Standing Water 4 6 R (N WELL DESTRUCTION ❑ BOdom vel Pxk ❑Uncned ❑Other ` Well piamemr ie TNa1 Depah �R Dm6 m Water B ❑Casing ei be Perforated Isom_R m_R Seting MMeriRl ❑Nut Cement(94/6 ha0/5-/0 yN ware,) ❑Send C..,.=.,,,k ma/7 gal caner ❑Benwitite Pellets ❑Benlonim(20%solids) ❑Manufacmmr Spa Yasvlet V,. Naen ❑season File ❑See, suBmitted Placement Method Ea-raped ❑F.Fall ❑Other C SP H 9/11:f G �QAC {N!H � 1T) llnC) O Complete with INuatmDrn Cep It below 12x;4 Compmte m Ex fining Surface Pad 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT TH6 WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCE$STATE LAWS,AND RULES AND REGULATIONS I ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. MINI OUR VANCE NOTICE REQUIRED FOR SPECTIONS-PLEASE CALL(209)95J 7697 { Tor sICNED t'g' TITLEe • J DATE t N J O N O N D AE P DEPARTMENT USEONLY ��(f,,..�� kppliatian A=pwd By Dam 31-311E)3 Area RL_ EmployeeIDR Grout Inspxrion By Date ❑ SPECIAL Well Permit J�1qq Pump lnspeaiw By / Date �f 13 WAIVER Received `7-J Deswction lespeetion By W• N61 Date U-y-❑ J Cnnamueted Wal Deptb rt COMMENTS PE I SC R—Wed _ Amount PermlU Codes Into B Mh Remitted Dale Service Re vast M least'.9 WNI IM $ 3;Z-0 Lk,p 00 EHD434D-0 MAWER WATEa WEU-PEAMIT ' Ivf✓zgoz