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WELL(PUMP PERMIT <br /> SAN JOAQUI N COUNTY EM•IRONMENTAL HEALTB DEPARf'NEN f 600 EAST MAUN S rREcr-STocicroN CA 95202-(209)466.3420 <br /> .' NON-R ffNAA8LF-PKRMIT _ ( _ EXPIRES I YEAR FROM DATE ISSUED <br /> JOS ADDRESS <br /> 5-� ([ L._ �__�. � L- C.nv/7a► EN1 's 9Ssj <br /> (1a0aa STREET _ .__�/ . _— _ A!'7 /v^ 1 <br /> r�` <br /> OWNER NAME ��-0.!t ,E <br /> OwNERADDRE11* FCITWSTATXlZAP <br /> CONTRACTOR /,E/, ��� -�V ,fle— <br /> PDONF'�' <br /> CONTRACTOR ADDRESS /O 70 -JC!% � CITwSTATVZIP <br /> SUPCONTRACIOR PRONE <br /> SUBCONTRACTOR ADDRESS C11%/SI"AI'E/ P <br /> LIcENsE 13C-57 C-61 ❑D-09 ❑Other NUMBER O ExnRATm DATE <br /> GEOGRArmCAL1NFO L%-tTON: Coordlnates X Y 1'oa-nship_ Range Section <br /> INTENDED USE ❑Domestic/Privatc lmotion/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Samp'iu*Characterriatbv <br /> ' ❑Pablic Water system <br /> IFditrcr a frcn,0,.cat W w S)w:m Name Cmxst Nsmc a Phone Number <br /> TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Altcratio uMet6fication ❑Test Hole ❑Other <br /> ❑Monitoring Welks) numberof—IIs Cl Soil Boring($) nu*t fbaimp ❑Geotcebsucal aovly fb,iug <br /> ❑Well Destruction ❑Out-Of--Service Well ❑Out-0f-Service Weil Renewal <br /> New Pump ❑Pump Replacement ❑Pump Ra ❑Cross-Connection Repair <br /> WELL CONSTRUeDON <br /> DriR'ieg Method ❑Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Other <br /> Proposed Well Depth R Excavation in diameter 13 Open Bottom ❑Gravel Pack/Gravel Sim in diameter <br /> ❑Conductor Casmg m diameter / Conductor Casing Depth fl <br /> Well Casing Diameter_m ThicknesiaGaugwAST A Schell ❑Stcel ❑PImc ❑Stainless Steel ❑Other <br /> Groat Seal Depth fl ❑Neat Cement(941b bag/5-10 gal Bwer) 13 Sand Cement sack mix/7 gal water <br /> ❑Bentonite(20%solids) 1 ❑Maauficnner Spec%solids_% Name O Specs on File ❑Spas Submitted <br /> Groat Placement Method ❑Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑Other._ <br /> n Concrete Pedestal Dimeusions: V/idth_ft Length_ft Thick in ❑Christy Bax ❑Snare Pipe <br /> RMP .ub=.,;blc Turbine ❑Otixr HP I'ump Sct It Standing Water Level lrn R <br /> WELL DES-rRvc-n N ❑Open fIouom ❑Gravel Pack ❑Uncased ❑Other <br /> Well Diameter_in Total Depth ft Dcpth to Water it ❑Casing to be Perforated from_ (i to R <br /> Scaling Material ❑Neat Cement(941b bag/5-10 gal%wer) ❑SAM Cementwck mix/7 gal water ❑Bentonite Pellets <br /> ❑Bcnionite(20%solids) ❑Manufacturer Spec%solids_°�o Now ❑Specs on File ❑Specs Submitted <br /> Placement Meshed ❑Pumped ❑Free Fall ❑Other <br /> ❑Complete with Mushroom Cap R below grade ❑Complete to Existing Surface Pad <br /> 1 TH <br /> HEREBY CERTIFY' AT I HAVE PREPARED THIS APPLICATION AND TRAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE IT E CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS <br /> I IInI R AVViiNCF NOTIFOR I\NPFCTION S <br /> SIGN ------- TITLE <br /> P A YjWE�N r <br /> 14­ <br /> SEP 13 2018 <br /> sLT DO PgR7y <br /> DF ARTMENT "F. LY <br /> Application Accepted By ate Ar.:t _ Employee 04. <br /> Grout Inspection By DateSPECIAL Well Permit <br /> Pump lnspectionByA, � D.,A0� tMO\ ❑ WAIVER Received <br /> Destruction /�B/y� `A Date Constructed Well Depth_ ft <br /> COMMENTS <br /> PE <br /> PE SC Received hec Amount Date Perrow Invoice Weft Ilk! <br /> Cod Info (/ 9stalfted Sen-ke Request E <br /> Akc� l0 Cl <br /> EHD 33-02-006 WEB Well Permit and Dcclaranon.doc <br /> 9/11/2007 <br />