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WELL(PUMP PERMIT <br /> t SM JOAQUIN CMiNTY ENy1RQNMENTAL HEALTH DEPARTMENT 690£AST MAN STREET-SLOCKTON CA95202-(299)46S-3420 <br /> NQN-R92NPAR1,E?W-T� y^I /( EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOD A,mtu'« � '� �....._ ._..`-L _!Wr <br /> CS 7a►y.L�tiDEN� ..e�>G,�+)'7�_ <br /> CUD-%STRt:ET Al}h� 'mit-✓V�-- PMCEe�St[�r .t--- <br /> OwNF'RNAML' L{n F�X�✓y Iy� L�� OGV�L��iC�� � NEr --r —S/�� <br /> Owsu ADDRESS _ �v (!y/ � -nIC/DIY/SIT,A/T�F17,7P..____._„_...._...---'."-X/-.'a� <br /> CONTRACTOR 7�-_ G(/ /�(//J� _//(/��SQL✓' (/t�G PHONE <br /> CON TRACTOR ADDRESS /O(D_ --�`v -- CITirtSrATFAZIP <br /> SUBCONTRACTOR <br /> SUBCONTRACTOR ADDRESS _ _ __ Cnv/'S7T'mF/7.tP-.____ <br /> WCENSE 0 C-57 C-61 0 D4)9 0 Other NUNWR ! E1(PIR1TtM D.ITE�Q.�J��� <br /> GEOGRAPTACALLNEORAuTiON: CoardiBates X Y TewTnhip_ Range__ Section <br /> iNTE't-11 USE 13 IMmesticiPrisatc lirigation/Agrleuhural 0Industrial 0 Water Quality Monitming 0 Soil Sampling:Chamct.'rixatitm <br /> ❑Public Water System <br /> IfdimruEcc tru .4 Waa S)S ..Xm eu�mL)Tame aCPtloe V:cnb._ <br /> TtPEOF WORK D Naw Well 0 Replacetnew Well 0 Well AlteraiioniModitication ❑Test Hole ❑Other-- <br /> 0 Monitoring Welks) <br /> ther0MonitoringWelks) "°1OsCTDf.a, 0 Soil Boring(s) 0Geotechnical �"'�afh<iugs <br /> 0 Well Destruction ❑OutofScrv"Well ❑OW-0f-kniee Well Renewal <br /> Ncw Purno, ❑Pump Replacemm ❑Pump Repair 0 Cress-Connection Repair <br /> WELL CONSTRU0610N <br /> Dr9Neg Method ❑Mud Rotary 0 Air Rotary 0 Auger 0 Cable Too) 0 Ptr1)Point 0 Odncr <br /> Proposed Well D^ph R Excavation in diarnuicr ❑Open Bottom 0 Gravel Pack i Gravel Size in diameter <br /> 0 Cooductor Casing in diameter / Conductor Casing Depth fl <br /> Well Casing Diameter—lo ThickncsvGaugerASTM Schad ❑Stcel 0 Plastic 0 Stainless Steel 0 Other <br /> Great Seal Depth ft0 Neat Ccment(94 lb Lag/5-10 gol„mer) 0 Sand Ccmcm sect mET f 7 gal eater <br /> r 0 Bentonite(20%Solids) ' 0 Manufacturer Spec%solids_•o Name 0 Spees on File ❑Specs Submitted <br /> Grow Placement Method 0 Pumped 0 Free Fall 0 Other 0 Retardant i Accelerator(name) <br /> PEDESTAL InstaDed By 0 Driller 0 Pump Contractor ❑Other.__ _—_—�__— <br /> ❑Concrete Pedestal DlmeRdan: Widtb_fl Length_ft Thick m 0 Chrhty Ilex 0 stave Pipe <br /> Pude ubmersible Turbine ❑Otter HP ftW Sct__tl Standing Watcr Levelfl <br /> WELL DESTRUCEI N 0 Open tom 0 Gmvcl Pack 0 Uncased D Other_ <br /> Well Dian e.ter__in Tota)Depth fl Depth to Water it 0 Casing to be Perforated from__._�R to fl <br /> Scaling Material 0 Neat Comm(941b Lag/5-I0 goal»mer) 0 Sand Cemeniwct mix/7 eal wwrr 0 Bentonite Pellets <br /> 0 Bentenite(2M" solids) 0 Mwr;t&w=Spec%solids_% None 0 Specs on F•ilc 0 Specs Submitted <br /> Ptacement Method ❑Punk 0 Free Fall 0 Other <br /> ❑Complete with Mushroom Cap fl below,grade ❑Complete to Existing Surface Pad <br /> I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DOME IN ACCORDANCE WITH SAV <br /> JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS. I ALSO CERTWY THAT }tY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WIT CALIFORNIA CONTRACTORS STATE LICENSE 130ARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS <br /> SIGN __ TITLE Gwy.�L DATE <br /> R�YMFR <br /> Sip <br /> C��VQ <br /> 3 <br /> J <br /> Ty 4E�MFHTUN�y. <br /> gRT)y NT <br /> .D ARTME:v-r - yt,Y <br /> Application Accepted By Dale b �1ra_ Employee ID= <br /> Grout inspection By Date PECIAL Well Permit <br /> Pump lnsil-tion By — _ Date ❑ WAIVER Received <br /> Des.'rucsionnon B - Date Constructed Well Depth_ ft <br /> COM.MFNTS1 1)n C-0 Int <br /> PE SC Received Amount Date Permw Invoice# Well ID# <br /> C Into acb edZ. I Service Request# <br /> W � <br /> EHD43-02-006 WEB - WeflPenrutmWDeclaratioo.du: <br /> 9/11/2007 <br />