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WELL 1 PUMP PERMIT <br /> SANAN JOAQUIN COUNTY ENYiRQNMENTAL H DEPARTMENT 3M£WEBER AvE 3% Tp('KTON CA 9002 -(259)fdrlF3420 <br /> NDN-REFUNDABLE PERMIT CALL 2119 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> v. <br /> Z <br /> M <br /> JOB ADDRESS F'fJ ✓� CITYme <br /> i <br /> S"f 3 p <br /> CROSS STREET �l a _ APN�/'ri� - _ PApeEL SIZE - —- 1 <br /> OWNER NAMC PHONE JI <br /> 01YNER ADDp£38 <br /> CONTRACTOR ,� pqL _ __ PHONEY <br /> CONTRACTOR A➢DRPSS�t-Oi-{) �I!/�'/ C•S-_ - _ CRYt.WATEILIP , <br /> SUMONTRACroR ��-•�/ PRONE <br /> 3VBCONT'RA4T0R ADDRFS4 CITYMA'rE/ZTP <br /> L1[ENSE DC-57 MC-61. 0 D-09 (3 Other NUMBER �a• EXPIRATION DATE <br /> GEOGRAPRICALINFORMATION'. Coordinates X Y Township Range Section <br /> t <br /> INTENDED USE O Dnmesric/Pnvate ❑IrrigatitmlAgriculturgl Q(mtustriel ,ARJYater Quality Monitoring O Soil SamplingJCharacletimtion <br /> 0 Public Water System <br /> lr dir(r 'I.M c erWsen vs ern nme tumor sme ar um <br /> TYPE OF WORK 13 New Well O Replacement Well Cl Well Altemation/MDd)fication 0 Test Hole 13 Other <br /> I !�'Monitaring Well(s)� <br /> --r-11.—Us Q�l Boring(s) number nfaarinlp DGWtechnical TM+^ attwrin� <br /> Ll Well Destruction 0 Oui-Of-Service Well 0 Out-Or-Service Well Renewal <br /> 0 New Pump Cl Pump Replacement 13 Pump Eseir 0 Cross-Connection Emit <br /> WELL CONSTRUCTt NI <br /> Wiling Method ❑Mud Rotary 0 Air Rotary '�r ugcr 0 Cable Tool 0 Push Point 0 011tu <br /> I I Proposed Well Depth, & �_ ._ft Excavation f_in diameter E3 Open Bottom 13 Gravel Pack/Grave7Si= indiarneter ry, <br /> I 0 Conductor Casing in diameter 1 Conductor Casing Depth R + 1 <br /> Well Casing Diameter_,7_in ThickneWGaurJASTM Sched 1W (3 Steel 0 Plastic ❑Stainless Steel A Mer <br /> I I Grout Said Depth__�I/ R Iqt Cement(94 ib lxrg/S-!5 gu!uv+ler/�Aa� 0 Sa Comeau Turk noir 17 got water <br /> U Bentonite(20%solids) 13 Manufacturer Spec%solids % Narne pees oryFile <br /> 13 Sp Submitted <br /> Grout Placernent Metbod Wumped 0 Free Fall ❑Other e[ardan Aeee7eratflr(name) <br /> PEDEgTAL Installed By �"Iler ❑Pump Contractor 0Other <br /> f 0 Concrete Pedestal ,Dimensions: Width_ft Length ft Thick in riaty Box Cl Stove Plye <br /> PUMP 0 Submersible 0 Turbine C Other HP Pump Ser ft Siambng Water Level R <br /> WELL DESI'RU'MQN 0 Open Bottom 0 Gravel Pack 0 Uncascd D Other <br /> Well Diameter in Total Depth R Depth to Water ft 0 Casing io be Perforated from ft to R <br /> Sealing Material 0 Neat Csment ryt Ib hag/3-IDAw!tr.rltee) 0 Sand Cement AX.k mix l7 gat water O Bentonite Pellets <br /> 0 Bentonite(20%solids) 0 hlsnufacturer Spec%solids % Namp R Spccs on File []Specs Submitted <br /> Piacemeat Method 17 Pumped M Free Fall 0 Other <br /> 0 Complete with Mushroom Cap ft below grade 0 Complete to Existing Surface Pad <br /> 1 HEREBY CERTIFY THAT J HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> I 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 /> M1NIMUM 24 HOURADVANCE NOTICE REQUIRED FOR INSPECTIONS—PLEASE CALL(209)953-7697 <br /> SIGNED TITLE r DATE <br /> L 41 <br /> Y <br /> A IRA- <br /> 1T D A <br /> f <br /> ru <br /> EV <br /> I)DEPARTMENTUS N Y <br /> Application Acceprc t Area E�yViP.1 <br /> FJ ul n <br /> -HEf#'TYd4}C'4� <br /> Grout]nape 'ur ay Dare z-3 �tC❑ SPECIAL Well PCrrtlil <br /> Pomp inspection By Dace ❑ WAIVER RPeeiv0d <br /> I Ucstrucrion lnspetyjon By Date Constructed Well Depth It <br /> COMMENTS h-• - "] <br /> C./ ' <br /> PE SC Received cb= Amount �k Per <br /> m1V Invoices WtifIDP <br /> Codes 100 B Remitted Service Re unt fj <br /> f p- a 5 3 �- <br /> 1dvv� a i' <br /> END 43-02.006 MASTER WATER WELL PERMIT <br /> 12!6/2002 <br />