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WELL 1 PUMP PERMIT {/ / �y �l SAN JOAQU COUNTY ENVIRONMENTAL h_1`I1DEPARTMENT 314 E WEaERAYE 3"�, mow/ 2 2 NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES I EAR FROM DATE ISSUED JOB ADDRESS L �y A r f t �""'� - C1TYlZlP J!1✓�Y �s , a CROSS STREET ` W APN -! Z"00dW 1 PARCEL S17E ' LAND USE APPUCATION N 0911t, yn j� OWNER NAME 11 ` r1� .{/y', _ PHONE W7/��a'7/ OwNERADDRESS a - /ler"i r_- / Crn/STATEJZIP fly��J -,S�3 CONTRACTOR Et�I © ./T IHIJt 4 L,4I, ,0/ : ^��G _ PHONE /H�Jf7 -Sre 7-377 CONTRACTOR ADDRESS o J n&,S-1k _v� CriYISTATEIZIP C- 9S4VO SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS CrfYISTATFJZ1P e/ LICENSE C-57 ❑C•61 ❑D-09 ❑O1her NUMBER rC llv EXPIRATION DATE GEOGRAPHLCALINFORMATION: Coordinates X Y Township_ Range Section_ INTENDED USE ❑DDruMdCJPrivate ❑Irrigation/Agricultuml O Industrial 0 Water Quality Monitoring CFSoil Sampling/Characterization ❑Public Water System 1fdif Trot Mom Owner: uer Ynrm ame tact — ^• TYPE OP WO Rx O New Well ❑Replacement Well 13 Well Alterstion/Modification ❑Other - I ❑Monitoring We0(s) #of wells 13 S0 Borings) x ofbo,inp Or..tb.i.1 x afbo hg, ❑Out-0f--Service Well ❑Oul�OFScrvice Well Renewal ❑Cross-Connection Repair ❑New Pump D ftmp Replacement 0 Pump R air WFILLCONSTIMCHON Drilling Method ❑Mud Rotary ❑Air Rotary [$}Auger 13 Cable Tool Cl Push Point 0Other -t Proposed Well Depth 5-c27 R Excavation in diameter Cl Open Bottom ❑Gravel Pack/Gravel Size in diameter ❑Conductor Casing _ in diameter ! Conductor Casing Depth ft Well Casing Diameter_in Thicknes��`al///Gaugc/ASTM Schell EFStcel L❑Plastic E3Stainless Steel 13 Other Grout Seal Depth ft l$leat Cement(941h bag/3-10 gal xwter)rr&"�❑Sand Cement sack mix/7 gat water D Bentonite(203'9 solids) b Manufacturer Spec%solids % Name At O Specs on File ❑Specs Submitted Grout Placement Method ❑Pumped ❑Free Fall d Other ❑Retardant I Accelerator(name) PEUESfAL Installed By ❑Driller ❑Pump Contractor ' ❑ Other ❑Concrete Pedestal Dimensions:Width It Length R Thick in 0 Christy Box O Stove Pipe UMP D Submersible ❑Turbine ❑Other HP Pumpp-Set ft Standing Water Level - fl I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN ?R. JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS U CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL n WORKERS COMPE SATION LAWS. M INI �/py HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS SIGNED_ 4WLt+�S C VI TITLE-:f4 _. DATE , 46 N 3 H DEPARTM'ENT USE ONLY Application Accepted By '' Date ,3 D O Arca 8nsployee 1b# Grout Inspection By Data 2 p6 ❑ SPECIAL Well Permit Pump Inspection By 411 Date ❑ WAIVER Received Constructed Well Depth R COMMENTS PE Sc Received Ghee Amount Dale permit) Codes Well[Dp Codes Info B Cash Remitted Service Request# 4379 15U 303p 3ff-0.u—V :36-1v 0 END 43-02-0ae WELL PLRNP PERMIT In7atws