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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HGLTR DEPARTMENT 304E WESER AVE 3—FL-SIOCIcron CA9SJO2-(S09)46g-M2G <br /> NON-REFUNDABLE PERMIT CALL 209)95}7697 FOR INSPECTIO%S EXPIRES 1 YEAR PROM DATE ISSUED <br /> JORADDR /� Cm21P O p, <br /> • cities;SITIE¢T APN .N/���J� d�S' PARCEL SipF '?-7 V� g <br /> OWNER NAME PHONE <br /> ORNERADDRESS CRVISTATEMIP <br /> CaNTRALTOR 9%ms-L C T �� PNDNE ( , <br /> CONTMLTORADDReu ..M1/ �e .f e�.e C YIJ II '� CEIY/STATEMP <br /> SancvN mlk PRONE O <br /> gUREUNTRAC RADMM Cm/STAmZIP <br /> LHIENSE C-57 6i 13D-09 ❑Other NUMUR EXMRATDN DATR f_ <br /> Ggn1:RAPRICALINTORMATION: Ceasilnhs X Y Tomishlp Raoge_ Satan_ <br /> INrC+DED um OrDnansficftvat, ❑Irrigelion/Agri<ult tst ❑Idusttial ❑Water Quality Monitoring ❑Soil Sempling/Clunctmemon <br /> O Publie Water Systarre <br /> iratnaenineA .w .ren sew m a, u <br /> TYPEOP WORK ❑New Well O Repiscemenl Well O Well ARmtionlModigullon ❑Test Hole ❑Odter <br /> O Monitoring Well(.)_ "wnei oPWOIf` OSoil Bodng(a)_ eieie°f Of eon"� 13Ceoteehnicel nwpW of bonny <br /> ❑Well Deshucta. ❑Gut-Of-Service Well OOut-OfServim Well Renewal �1�•``\Vr <br /> w Pump ❑Purnis Roplacommett ❑Pump Repair ❑CmeaLamadon Repair <br /> WELL CONrrsax nON <br /> DAUbg Method ❑Mud Roury ❑Air Rvury O Avgar ❑Cabte Tool ❑Push Point ❑Other <br /> Pnpmad Well Depth At ETcavation indiameter ❑Open Bottom ❑Gravel Pack I Omvel Sia in diameter <br /> OCeducmr Casing indim:ter / Condmbr Casing Depth ft <br /> Well Casing Diameter_in ThickneesrGauge/ASTM Schd O Sael O Phaic ❑sud.lessStat OOther <br /> Gana SW Depth fl ❑Neat Content(94 l6 Aug/3-10 ga/awfe) 13S.W Cement oak ante 17 gal <br /> ❑Bevmnite(20%alids) ❑Manufacturer Spec%solids_% Name ❑Speosm File OSpeca Submitted <br /> Groat Plaeemeel Mahod ❑Pumpd ❑Fra Fall OOther_ O Retardmi/Accaemmr(sone) <br /> PEDPJITAL Installed Rv ❑Driller WPumpCwhator ❑Other <br /> I&O.note Pmlestal Dlmen.bm Widthitlm hHP R Thick in ❑ChrW,Be. OStew Pipe <br /> POMP W4.1naersible ❑TYrbinc ❑Other__ PumpSa�/ fl SmdivgWewLevel //6 ft <br /> WELL DPBrav"oss ❑Co..Bottum O Gravel Pak O Utwamd ❑Uther <br /> Well Damaer_in Tout Deplbft Depth b Wear ft O Casing W be Perbmtd Bore_D m_R <br /> • Sealing Materiel 13 Nest Cement(94lb lsry/3-l0 ga/warrr) 0Smd Cement sock mix/7 pi water Cl Bentonite P.Heu <br /> ❑Bentonite(20%solids) 0Mau6eemrer Spa%olid. % Name ❑Spcuon Pik OSpecs Submind <br /> Plaoesnt Messed O Pumpd ❑Fra Fall ❑Other <br /> ❑Conkplm with Mruhtoom Cap ft below grm& ❑Catnplm to Existing S.1.Pd <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 1 ALSO CERTIPY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH A L <br /> WORKERS COMPENSATION LAWS <br /> 11LL IUB HOUR NCE 9TICEREQUIREDF SPECTIONS—PLEASE CALL(209)953-7 7 <br /> SIGNED �•�' i� TITIE DATE <br /> If <br /> _LLIOWNot <br /> IG —_ <br /> E <br /> DEPARTM:NT USE ONLY <br /> Application Ae, SY Dae JO/S=03 Ara Employs IDi0 <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pam,lesPatimt Date /Z-9-03 ❑ WAIVER RIN:91Yed <br /> Dbhucdwf Inspection By Date Crraslrueeni Wal Dwb D <br /> • COMMENTS <br /> PE Sc Raavd ec Amount Due Petdtl ]..k.Is Well Halt <br /> brio bfo este RtMnd SIMI. sest0 <br /> O DSO 23 3 7�— ID a <br /> 03 <br /> I <br /> BHD43{2006 MASTER WATER WELL PERMIT <br /> I V6120M <br /> j <br />