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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNIY ENVIRONMENTAL HGLTR DEPARTMENP 30CE WERM AvE 3"PL-STOCIcron CA 95202-(209)66Bd620 <br /> FADD� <br /> UNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED m <br /> 4 ¢ Iyar�s �J�^� S ��` �'� �1 ,�y� _ CDQQV/7JP <br /> LI' Le'Y ` APN /LD.J VO/PARCELSIE2V•s-LANDUSEAPPLIf TTIION#w / /.�. p S •N� PHONEe { ggRFS4 - CHV/ftATe/ZIP �y p 'JR PHONEEd3iS --2A/ORADDRF55 6� _ �D�tti /S� CT'lSTATE2IP <br /> PHONE <br /> SURCONTMCTOR <br /> SUECOwT t:rOR ADDRL45 CRY/STATEJZIP o _ <br /> LICENSE ❑C-57 ❑C-61 ❑D-09 tber � NUM ES, f E..&N DATE I <br /> GEUGRAPHICALINFONMATION: Comediennes X V Townahlp_ Range_ Secdmm_ <br /> INrp�sD Us ti."ivme ❑hrigation/ cultural ❑Industrial ❑WeW Quality Monitoring ❑Soil Sempling/Chueco rimrion ' <br /> ❑Public Water S aura urcm • ..'1 <br /> HOEenm OemVJ' <br /> TvPEOPWoNE ❑New Wcll ❑Replecmimt Well �Vcll AlterasioNModifiuDm xorroC ha eofainim U"/ <br /> 13 Monitoring Well(.)_#of wells ❑Sail Borings) O Gentechniwl <br /> ❑Out-0fService Well ❑Out-0f-Service Well Renewal ❑Crose-ConnMimn Repair <br /> ❑New Pum ❑Perep litcplaccarent Cl Piunp Repair <br /> WULCONIMMMON <br /> Drilling Method Cl Mud Rotary O Air Rmary ❑Auger ❑Cablc Tool ❑Push Point Cl Other <br /> Proposed Wall Depth 0 Excavation in diameter ❑Open Bottom ❑Gravel Pack/Gravel Sim b diamettr <br /> ❑Cm,b,mCuing iodiamaer ! Conductor Casing Depth ft <br /> Well Casing Diameter_m Tmclmc%AGaugr/ASTM Schcd ❑Steol ❑Plusic ❑SMlalcu Steel O 6Xhe, <br /> Grout Had Dcpth fl ❑Nees Cement(941b ba915-I0901 wmer) ❑Sand Cement sack mfx/7 gel water <br /> ❑B sumbe OM solids) ❑Mmufecsu cr Spm%solids_% Name ❑Spec.on File ❑Specs Submitted A <br /> Grout Pheement Method ❑Pumped ❑F=Fall - ❑Other ❑Retardant/Accdenum(name) <br /> PFDPSTAL In.tdkd 8Y ❑Drilla ❑Pump CovDxror ❑ OIM1a <br /> ❑Concrete Pedeshl Dimensbu:Width_fl length fl Thick in ❑Christy Bos ❑Steve Pipe <br /> PUMP ubmeraible ❑Turbine ❑ONa HP Pump Sa ft Bantling Waer level ft <br /> 1 HEREBY CE TIDY THAT I HAVE PREPARED THIS APPLICATION AND TNAT THE WORK WILL eE DONE IN ACCORDANCE WITH SAN <br /> CURRENT AND ACTIVE WITH HE CALEPORNIA CONTMCTORS STATE LICENSE BOARD NDRTHAT 1 AMTIN COMPLIRED <br /> NCE LWITH SALL <br /> WORKERS COMPENS O WWS. <br /> _ UM 24 HOUR ADVANCE NOTICE It�Q�ED FOR INSPECTIONSDA�� /y-U� <br /> SIGNED TI'n.e •�- O <br /> J <br /> E D <br /> DE ARTMENT USE/-ONXV / ,( <br /> m Ams 46 Employee IDN <br /> AApplicationAccepC3 SPECIAL <br /> Well PeTrnH <br /> ted B <br /> Grout Nspecdon y Date C� <br /> Pump Inspection <br /> By '� Onto � 26-;7 ❑ WAIVER Received / <br /> Constructed/Well pD/�epth ;I � R 1 <br /> ;RRN;p <br /> 6 IT"a.D6j S"Iwf NKA h1.!' f � �/Kzed >� aAAs ' (`BY- 0 av, <br /> SDale Permit, Invoke# We111DM Service Dnl# <br /> p9C L}2 5� <br /> WELLHIMe TERanT <br /> MoOK-0]a \ <br /> imfaaps <br />