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�,. WELL/PUMP PERMIT <br /> P ✓ <br /> j t , 'SAN XAQ14-RE tN COUNTY EPE MibttTTAL HEALTD DEPAATXL<T 600 E.4n MALK STREET-S(OCKTON CA 95202-(�466.3420 <br /> N014-REFUNDABLE PERMIT EX.PPII(REE�S II YEAR 11FROM DATE ISSR�j i <br /> 70a ADDRESS ,G� l 1{3dS Lr C""Z" <br /> CROSS STREET W APV -^Ln PARCEL <br /> SIZE f�— <br /> OWNER NAME 1�/^ -` I T <br /> OMNER ADDREss IY CITY/SfATLgJP r1rAN <br /> /y 7 ' <br /> CONTRACTOR ��..W{'').1-1.#�/J � PHONE �i�fiT^Z`Lgp � <br /> CONTMCTOR ADDRESS t} <br /> � S `• l Z 6 CI'IY/STATilT1P (-)S <br /> SUBMNrRACFOR PDON-E <br /> SUBCONTRACTOR ADDRESS CITYfSTXrErz1P _ 1 <br /> LIMSE O C-57 Nk6k O D-09 O Otho VUMDEA E.11P1R.1TI0.<D.tTE <br /> ` GEOGRArIIICALINFORat TION: Coordlumes X Y TeRmshtp_ Rangel StK•Wa <br /> IN USE 'e Private D ImpbonAgncultural O Industrial O Watcr Quality monitoring O Soil SamplingCharaeu9tzadon <br /> Public Wafer Sy5lelo <br /> IEdiff¢�frrn: Conner Nau.or Ph—NuMba <br /> TYrE OF WORK D New Weil 113 Replacement Well D Weil AlteratitwModit&aiion O Test Hole O Other <br /> D Monitoring Wells) numbero�Rs D Soil Boting(s) Amb.`°rbostgs; O Geotechnical u®hcr vtt,.tag` <br /> Well Destruedon O Out-OfScrviee Well O Orn-0E-Senice Well Reuowal <br /> New bunp 0 Pury Replaccumnt D Pump litzpair O Cross-Connection Repair <br /> WELL CONSTRUCTION <br /> Drilling Method D Mud Roar) O Air Rotary O Auger O Cable Tool D Push Point O Other , <br /> Proposed Well Depth ft Excavation in diantefer O Open Bonom D Gm%T1 Pack i Gravel Size in diameter <br /> O Ceaductor Casing in diameter / Conductor Casing Depdt ft <br /> Well Casing Diameter in Thickness/GaugeIASTM Schell O Steel O Plastic D Stainless Steel Cl Odxv i <br /> Grout Seal Depth 0 O Ncat Cement 194 fb bag;S-1 ogal w vw) O Sand C•n= .sack mix r 7 gat water <br /> D Bentonite(20%solids) O Manufacturer Spec%solids_45 \ane O Specs on File O Specs Submitted <br /> Grunt Pleemeat Method O PwTcd O Free Fall O Other D Retardant:Acca-lerator(name) I <br /> PEDMAL Installed By O Driller O Pump Contractor O Other <br /> O Concrete Pedmizi Dhuensions: Width_ft Length_ft Tbick in O Ch"Box O Steve �_— <br /> PuMr .tbtaersible D Turbine D Other HP Puny Set ft Standing Waur LevTJ C2, 11 <br /> WELL.DES7Rumo% D Open Bottom O Gravel Pact D Uacascd D other <br /> Well Diameter_in Total Depth N Dcpth to Water_ @ O Casing to be Perforated from ft to it <br /> $wince material O Neat Cement(9416 bag:5-10gal anter) O Sated Ccmcnt sack ntt;17 gni water D Bentonite Pellets <br /> O Bentmite 00%solids) 0 Manufacturer Spec%solids_So Name O Specs on File O Specs Submitted <br /> PkftvmW Hefted O Ptumped O Free Fall O Other <br /> (3 Co tete with Mushroom Cap ft below grAdc O Complete to Existing Surlitce Pad <br /> I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE N ACCORDANCE WITH SAN <br /> JOAQ16LN COUNTY ORDINA.CES,STATE LAWS,AND RULES AVD REGULATIONS I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AVD IfrE THE CALIFOAVIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN C0NPLTA,NCE WITH ALL <br /> WORXQ CO <br /> TrrLE <br /> �1 <br /> Em C . <br /> MAY <br /> ENVIRONM <br /> PERMIT K EE <br /> IV in <br /> �',/ <br /> DEP USE Anna Il1q���,�L� <br /> AppticTM Apection I1ete <br /> Grout Inspection Bp_. Date 1 t f CLL Well Permit <br /> pump Itg-'-By V Date 13WAIVER Received <br /> 1111 "1 A <br /> Destruction Inspection By Date CODStmeted Well Depth pi )Y� <br /> COMMENT$ `cC <br /> PE sc Am~ PermwCo" 121111 Mq y <br /> Fo <br /> Rem Dateservice AS"A Invoke 0 Wd wo S48 <br /> r Z r JZ D6-7-7 `"O4 <br /> F <br /> h rH aO'yh' cot, <br /> MM 43-M-"WEB S <br /> 9.U�2007 <br /> Wei Permit and Deets mdoc <br />