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Mo — WELL/PUMP PERMIT - <br /> SAN 2OAQUIN COUNTY ENVIRONMENTAL HLALTN DEPART 304 E W9SZR AVL 3-PL-SI'OcxTQN CA 95202 -(209)468-M20 <br /> NON-REFUNDABLE PERMIT t r'- CALL 209 953.7697 FOR INSPECTIONS - EXPIRES4 YEAR FROM DATE ISSUED �n <br /> .IORAPDNrss ' 4 0. .�CZ2c Pt . .. crrvrla, 5filok4o, ciS:'1'7 rl <br /> ry '^ M 9 <br /> CROt�STRur (0�aa `��+ ,I s (� 1 APPN \+ - rt:PARLRL SIu � LANO UM APPLICATION O p <br /> O"LRNAME S.U/'� '{n1^W(1/•.1 /+'rTN(/`1�,/V nL1Vtans♦ A. V4e4. }PHONE ,aoty-g31-qbo GC <br /> OWrIRRADORLS4 �YO(lr•. LO MS't11C,I1 I•L✓. \ CITVISTATUZIP S t"j CA "'I�a/•J <br /> CONTRAcroRR'w((T�. .WCI�MrS rQLp4,V' p1mn, aa-dgej-o19Nl . <br /> CONTRACTOR ADDRIa' Y•O-OO)`, Lja Cel'TISIAITIGP Ute, e,- Qsd34 <br /> SORCONTMCTOR f�`/E PRONE x-77-396,'f <br /> SORCDN crDRAODRME - / CITT/STATEr2xP <br /> Cb <br /> LTcrosE 0 G5 ocfil 0D-09 '0Otha- 'i - NUMEER 1aaLpb ExnMT1ONDATLQS/teo9• <br /> GLOLRAMUCALINPONMATION: CDOrdlnRkrr X V Serdn-- <br /> INrENDED USE 0 D0nX*dC/Pdvak Oigagor)AViculknal O Induennal 0 Wem Qality Monitoring O Soil SRmplinyCh.nni.don <br /> O Public w W.W yftem <br /> tfdt :hom 0.wr: w .No, am. <br /> TaTE OF WORK 0Nrw Well, 0RWbcemen1 Well Well AllartioNMadi6wtion gOtha V, VA S.st <br /> ❑Monitoring Wella) pof wellq• OSoil Boring(,) a°fasdep . ❑Geotahniwl asfb—., <br /> O O.,-0fSc ice Well OOut-ofService Wcll Rmvwal. OCfoMCennatiao%apair.. <br /> 13 New Pnnni, O Purnp RciploxIacnt :0 Pump Anair <br /> WELLCONUcriON NIA <br /> E <br /> Dalling Method C)Mud Rotary""0 Air Robry ' 't 0 Auer ❑Coble Tool 0 Pueh Point E3 Otho <br /> Propsed Wsll Dryth ft FxwvaEon in diameter ❑Open Bottom . s OGavel Puk/Gavel Sine. in diimaa <br /> o <br /> I OCmWworCuing indiamekr / Conductor Cuing Depth A <br /> Well Cuing Diamekr_in ThicknessQuagelASTM Sched -0 Skel O Pkasc O Stainless Steel O Otha <br /> Grout Seal DrpN ft 0 Next Cement(941b bog/1-10 gv1 worn) O Send Cement mat mk/7 gal water <br /> i0 to <br /> Bennite(20Y.solid.) 0 fi <br /> Muuot.Spm%solids no% Na - 0 Spew on Filc 0 Specs Submitted <br /> Gmut Placemen Mahod ❑Pumped. O Fm Fall .I7 0dNr- O ReuNan0 Accelimwr(name) <br /> pEpE,gA{,V lutsikd By O Drilla 0 Pump Contractor O Other <br /> O Concrete Pedesial Dimension.:Width; R 1xn ft Thick in O Christy Boa 0 Stove if. <br /> PUMA U O Submervibk O Turbine OO:ha HP Pomp Sa ft Standing Wata Level fl <br /> I 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-MV REQUIRED LICENSE IS <br /> CURRENT AND ACnW WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL <br /> WOR 7MCEN3ATION LAWS. - <br /> MINJ7�7UM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> SIGNED w� ��f� Trite : �G/vL�'A__.'. . DATE O O' <br /> it r <br /> I <br /> I <br /> E <br /> � s <br /> ho <br /> �.....-.._..__�._ - - --- -- - r. <br /> i D RIP A TMENTSE NLY, - <br /> Appliweon Auxp Dates Am, EmploYex lDp A 'T'rT <br /> s�myu�t,WpatioF By Date a( O. SPECIAL Well Permit T`T <br /> UAL�r2 Aw4..�m Date•' ❑• WAIVER'Received <br /> Coutruted Well Dept h R <br /> COMMENTS- - Z •- <br /> PE SC Recaved Amount <br /> COdea I.F. By Cash R..m.d Min rvice Re uext0 Involved We11 IDN <br /> imrsros wrut nsMrrmeatr • <br />