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f _ <br /> � ~ � WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMKn 304 E WEBER AVE 3m FL-STOCICTON CA 95202 -(209)4611.3420 <br /> NON-REFUNDABLE PER'MIIT 7-71I CAI,L(2209 953-7697 rOR INSPECE <br /> TIONS EXPIRES 1 YEAR M FRODATE ISSUED <br /> JoBADDRESS - 13 CITY/ZrP S3 <br /> CROSS STREET IApN Loly. o&o..n`>r PARCEL SIZE 2-r-`O LAND USEAPPLICATSON N tA� <br /> OWNER NAME Vj I <br /> OWNERADDR#SS 1Inc CITWSTATElLIP <br /> COWMACTOR <br /> PHON <br /> CONTRACTOR ADDRESS 71 7 <br /> CrrY1S'1'wTTJIdP <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTORADDREss CIT//YISTATEMP-77 <br /> LtcENSE ❑C•57 CTC-61 0D•09 OtherNUMBER_1010Z3t-]L.- EXPIRATION DATE <br /> GEoGRAPHICALIN Anom Coordinates X Y Township Range Seetlon <br /> INTENDED USE tWPrivate IrrigationtAgricultural q Industrial Q Water Quality Monitoring ❑Soil Sampling/Characterization ` <br /> Of C3VUbliC Watercs <br /> [rdiRerentfrom Ohwrcr: seer ritem rme ooure um n um r <br /> TYPE OF WORK ❑New Well Q Replacement Well Q Well AhemtionlModificalion Q Other <br /> f Q Monitoring Wells) N ofwelis Q Soil Baring(.) Naf 6o i- ❑Geotechnical a arberinar <br /> Q Out-Of--Service Well O Out-Of-Service Well Renewal 13 Cross-Connection Repair (� <br /> Q New pu PUMP RePlSCMCMt Q Pum R it <br /> WELkCON6TRUCTION <br /> Drilling Method Q Mud Rotary Q Air Rotary Q Auger Q Cable Tool O Push Point Q Other 7�) <br /> Proposed Well Depth it Excavation in diameter 0 Open Bottom - 0 Gravel Pack I Gravel Sine _ in diameter rh <br /> 13 Conductor Casing in diameter I Conductor Casing Depth A <br /> Well Casing Diameter—in Thickness/Gaugr/ASTM Schell Q Steel ❑Plastic Q Stainless Sled n Other /1 <br /> Grout Seal Depth It Q Nest Cement(941b bag/S-10ga1 ttnfcr) ❑Sand Cement °i <br /> racmix!7 gee]wailer <br />' ❑Brntanito(2014 solids) Q Manufacturer Spec%solids_%. Name O S <br /> Spec.an File E] peea Submitted <br /> Groat Plseenwe a Method Q Pumped O Free Fall Q Other Q Retardant I Accelerator(name) ' <br /> PEDESTAL Installed By O Driller Q Pump.Contractor O Other <br /> ❑Concrete Fedestai Diruentdons:Width ft Length ft Thick m ❑Christy Box ❑Stove Pipe <br /> puarP Submersible E3Turbinc ❑Other HP Pump Set ft Standing Water Level ft <br /> I HEREBY CER FY 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. I 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 /> MIN UM 4 HOUR' VANCE NOTICE REQUIRED FOR INSPECTIONS J1 /yam/ <br /> SIGNED TrTLEIZ42 DATE <br /> uta <br /> _ VtF O <br /> 7-1 <br />` 71 / <br /> DEPARTMENT 6E ONLV <br /> Application Accepted ey Data /I -;{V Area Employee IDN <br /> Grout Inspection By Date 13SPECIAL Well Permit <br /> Pump Inspection By Dais ` CI WAIVER Received <br /> Constructed Wellpth B <br /> COMMENTS <br /> PE SC Received Chile Amount Perm1U <br /> Corks Info B ash Remitted Date Service best0 InYDICeN Well IDN <br /> -r1 osv l og SC. n '90a <br /> UND U-0]-006 �„� 1rE1.l..Pt/ArP PFJtMiT <br /> t/2]ItgaS � <br />