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WELL/PUMPPERMIT <br /> SAN JOAQVIN COUNTY ENVIRONMENTAL HE "DEPARTMENT 304E WEBER AVE 3"•F' -SD,:xToN CA 95302 -(209)461-3426 <br /> NON-REFUNDABLE PERMIT CALL(2091953-7697 FOR INSPECTIONS EXPI 1 YEAR FROM DATE ISSUED <br /> L <br /> JOB ADOR6tt CITy/ZIP <br /> CRDSSSTREET'[b'1`z'N ��Q\—T APN �7�Q �� PARCELSIM 30 $ <br /> OWNERNAME "eC��]TC��\n\���Q� X1 rCL1,, CPHO�NE�"aI� gR3r3O���o0 0 <br /> GWNER ADDRESS r .IN• �oY ��`-�� CTry/STATPJ21) 1�V�rwA(O�A, <br /> CIXcnau, OR ^`P.. CTL)7��'1y�• (��(�N ea��T\� <br /> CONTRACTOR ADDRESS CITY/STATEIZIP <br /> SUBCONTRACTOR PNONE 1•+`1� <br /> SUBCONTRACTOR ADDRESS \ �- WA CETV/STATEMP ((�� <br /> LKTNSE GS] bl ❑D-09 ❑Olbtr NUMBE0. EXPlaATTONDATEO�TI3OIOC.+ <br /> GI RAPNICALINMRMATIDN: Coordinates X V Township Range_ Section_ <br /> INTENDED USE matirlFrivate ❑Irrigation/Agrioulmnl DlnduTtdal ❑Water Qualily Mmiloving ❑Soil Sempfing'Chamctenecum <br /> O otic We.,S m - - <br /> trelBarmnTm,a� No.a <br /> avay. m ancr m <br /> TVPEOFWORK 0NmA Well ❑Replacement Well ❑Well AIlentiaNModifiration 0Tom Holc ❑Other <br /> O Monitoring Wells)_ '""'Aarera th ❑Soil Borings)_ Cl❑Geouchnieel ^u .Favi,, '�1 <br /> Cl WellDatrvction C3ut <br /> O -ofServioe Well ❑Out-or--service Wdi Remewel V, <br /> OHe.Pum Pump Replacement 13 Pump Repair 0Cmss-ComeclbnRepel, <br /> WELL CONSIAUCI'ION <br /> DAIII.g Method ❑Mud Ronny 0 Air Ronny 0 Anger 0 Cable Tao) 0 N h Poim 13 Other <br /> Proposed Well Depth R Excavation in diameter D Open Bottom O Gravel Pack/Gravel Si. in diameter <br /> OCmductm Coring indimamnr / COndmIm Ceaing Depth R <br /> Well Casing Diamcur_in TMcknae/GaugNASTM Schell 0 Steel ❑PIaBle O stainless Sial ❑Qhs <br /> Grout Seal Depth ft Cl Nat Cement(941b bug1340gW voter) ❑Sand Cement sw.k mu/T pl aetn <br /> O Bemonite(20%Solids) ❑Manufacturer Spec%solids_% Name OSpecson File OSpea SubmincA <br /> Gro.E Pbcement Method ❑Pumped 0 Fra Fall Cl Other 0 Reardant/Accelerator(nerve) <br /> PEDESTAL Imtalled BV 0 Ddllcr 0 Pump Contactor 13 Other <br /> 0 Concrete PedeMal Dimensions: Width_It LenSthft Thick in O ChrJsty Boa O Stave Pipe <br /> M <br /> PUP Submeniblc O Tmbim n Other His <br /> 3Q Pump Set j R R Standing Water Level <br /> WELLDESTR wN Cl Open Bottom 13 Onvel Pack ❑Unwed E3 Other <br /> Well Diameter_in Toul Depth H Depth to Water R ❑Casing to be Pcrtbrmcd fmm_A to_R <br /> Sealing Material O Neat Cement f94 Ib bug I S-10,nd Sore*) ❑Send Cement sock min 17 gal warn O Bentonite Fallen <br /> Cl Balonite(2W"solids) O Manufacturer Spa%Solids_% Name O Spee on File 0 Spas Submiued <br /> Placement Method 0 Pumped -'0 Fra Fall 0Other <br /> OCompletc With Mushroom Cap fibeloW grade O Complete to Exining Surrace PW <br /> 1 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. 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 /> MINIMUM 24 HOUR ADVANCE NOTI_Cg REQUIRED FOR INSPECTIONS <br /> $IGNEB A�y�j7 Q TITL6FM�L_AL DATE <br /> T <br /> D <br /> 004 <br /> OUNTY <br /> TAL <br /> TMENT <br /> Et <br /> EPARTMENT USE -T -a,���� <br /> Application Aacpled By ' to Arra Emphyyee IDN 1977 1�fa <br /> Gnu,Inspection By Date�� ❑3S SPEC IAL Well PH1RiT <br /> Pump Inspection Wte-L/LZLai� ❑ WAIVER Received <br /> Destruction Inspection By Pote Constructed Well Depth 0 <br /> - — <br /> COMMENTS /�ZJJ F�L�P17rlu�P / `y S �sEYI /�'L3 / g(�Itq — <br /> PE I SC AmoDry Cbecku Received Dale PnmiN InvoinN Well IDI <br /> Coln Info Remitted ash B Servlre Re unt9 <br /> 173(- 11 0 <br /> EHD 43-(YL-006 MASTER WATER WELL PERMIT <br /> snrzooz <br />