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WELL/PUMP PERMIT <br /> SAN JOAQUIN COENVIRON MENTAL HEALTH DEPARTMENT 30/EWEBERAVC3"FI SYOCETONCA9S2D2 -(209)46"20 <br /> NON-REFUN BLE PERMIT CALL(209)9.53-7697FOR INSPECTIONS EXPIRES I YEAR FRMM <br /> /O�I)ATE ISSUED <br /> 14 JOB ADDRESS J I CRT/ZIP -l("LI <br /> / � \ O <br /> CROSS STREET 6LO QN APN ��-070-03 'JPARCELSIEE <br /> OWNER <br /> • NAME P,4 a— PIONSZ � p <br /> (MERADDRFSS CITY/STATE/ZIP !� <br /> CON CPOR A). `, .I,P�/�✓/ TA ONE <br /> CONTRACfORADDRE95�I. /4• �- CrrY/STATFlLIP t <br /> SUBCONTHACTOR PHONE <br /> SUBCONrRALTORADDRESSTT Cm/STATEIZIP <br /> LICENSE OC-57 ❑Cbl ❑D-09 ❑OtherIU __ NUMBER EPIRAflONDATE Q� <br /> CEOGRAPHICALINFORMATION: CDDrdlnMea X Y Township_ Range_ Eeelfon_ <br /> IHTENDEDDSE WD..fic/Privete ❑ImgationfAgricultumt 0Inultamal ❑Water Quality Monitoring O Soil Sampling/Chatacmritation <br /> C Pal water Svstem <br /> Ifdtf B°m Dew un attm eh, N.eCta PW.NunlXx <br /> TVPEOE WORK ❑New Weil O Replacement Welt O Well A)umHoNModif[pnon ❑Test Hole ❑Other <br /> 13 Monitoring Wtlis n°mwefeerirg n°mw ofewinas \ <br /> --__ ❑Soil Borings) ❑Gwtahniul_----__ <br /> O Well D nexh.duo O Out-Of-Serviw Well ❑Out-Of-Service Well Rmewal �S <br /> U New Pum Replacement O pump,RqM, ❑Cros-Connection Repair �\ <br /> WPLLCONSTRUCEION <br /> EI Method O Mud Rotary O Air Rotary ❑Auger 0 Cable Tool ❑Push Point O Other <br /> Proposed Well Depth ft Excawtion___io diameter 13 Open Bottom ❑Gavel Pack/Gravel Sixein diameter v <br /> O Crnducwr Casing. in diamew 7 ComduowrCasing Depth__ ft <br /> Well Culmg Diameter_v, Thunk n..dGauge/ASTM Sched O Steel O Pham, 17 Stainless Steel ❑Other <br /> Grant Seal Depth R O Neat Cement(94 lb bag 15-10 gal eau) ❑Sand Cement sad:mix 17 gal water <br /> ❑Benwniu(20%salids) O Manufecmra Spa%solids_% Nan O Spec.an File O Specs Submined <br /> Grout PlacelRmt Method O Pumped O Fra Fall ❑Other0.emrdent/Acalmtor QWme) <br /> PEDESTAL Installed By O Driller Cl Pump Contractor ❑Other hl <br /> ❑Concrete Pedestal Dimemloas: Width R Length R Thick to O Christy Box 0 Stove Pipe <br /> PUMP Submersible ❑Turbine C3(Aha HP= <br /> P Pump Set A Sw4ng Water Leve R <br /> WFLL DMRUC1'ION ❑Open Somm O Gravel Pack O Untried O Other <br /> WBII Diameter_in Talai Depth ft Depth w Wwcr ft ❑Cadng to be Perforated from_ft w_R <br /> Snling Maurlat O Nat Cement f94 lb bag/9-10gel wwrrJ O Send Canrnt sack mD/7 gel water ❑Benwniw Pelleu �. <br /> • ❑Bmw.!W(20%solids) 13 Mmafhetuten Spa%solids_% Name ❑Spason File ❑Spee Submined <br /> Pi.eemenl Method O Pumped O Fra Fell ❑Other <br /> 0 Complete with Mushroom Cap It below grade ❑Complete to Exianng Surface Pad <br /> I HEREBY CERTIFY THAT 1 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 /> INIMUM 241IOU VANCE TICE REQUIRED IONS-PLEASE CALL(209)9153A697 <br /> SIGNS Tar DATE 7 <br /> Y <br /> sc <br /> At F;P <br /> M T <br /> DEPARTMENT US N Y r� / <br /> Application Accepted BY Den Q [) A. ✓2-1 EmPbYa lDer <br /> Grout Inspattm By Dau ❑ SPECIAL W ell Fer is - <br /> Pump inapation By Dare ❑ WAIVER Received <br /> Destruction Inspection Dau Constructed Wen Depth R <br /> COMMENTS <br /> • PE SC Received Checid/ AmountPermit/ <br /> Codes Info as RemfttM Daee Servl.R..I# <br /> Invoiap Wall IDN <br /> 43. 0 So•dA po p , <br /> EHD43-02.006 <br /> 12/6/3002 MASTER WATER WELL PERMIT ° <br />