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O = w �A <br /> X O o <br /> 71 <br /> � N 1 <br /> o O o m <br /> Cn g <br /> m O <br /> _ _ N <br /> C/) o rn <br /> fs�,Z (Q <br /> SAN JOAQUIN CDONTr A66-7A20 �- <br /> NON- ENVIRONM W $TOCKTON CA 95206-(209) <br /> REFUNDABLE P ENTAL HEALTH DEPgRTy ��L/P�JMP eE�..,M�T LTON AVENUE- FROM DATE ISSUED <br /> ER_MIT ENT r t �(pIRES 1 YEAR m <br /> JOB ADDRESS 2093.7697 ONI .;­A <br /> CROSS STREET -"�•� CmILP I <br /> ... / / .• {(AND USE APPLICATION a—� <br /> OWNER NAME 1 _-APN_ PEEL SIZ _ ..._ <br /> _ �•'^"' _ <br /> OWNER ADDRESSPHONE--r-"'� r�`---� --- <br /> CONTRACTOR 't �`��-- -- J CI - <br /> �r <br /> CONTRAPHONE <br /> CTOR ADDRESS,_ ---" - <br /> r'�� ClrrrSTATEIZIP <br /> SUBCONTRACTOR �li �� <br /> •`r" PHONE <br /> SUBCONTRACTOR ADDRESS <br /> �— CIT,1STATE(ZIP <br /> .- <br /> LICENSE �f�57 <br /> C-61 D.05 Cline, - EXPIRATION—2-1 <br /> EXPIRATION DATE�� <br /> DOMESTIC --- -- Nu�R <br /> WELL SAMPLING' General Mlneial!COhtom,Bac en3 1431,1) Dlbromoch�(4392) Arsenic(4393) <br /> INTENOEDU DPmCSnGPrlval!— Characterization <br /> galwnlAgncuaulal Intlusirnal pWaler puahly Momtonng - Soil Samp <br /> I. <br /> lm <br /> Puubllc Water System <br /> rlrerenl M1wn O—r Canlad Name u Phpro Numper <br /> War�.ysinm Nwn. <br /> TYPE OF WORK .T:hjeyy yyell RePlatCmenl Well _—_— <br /> Well Altera:iunR ioll-lion i::Other a o!Ixmrgs <br /> Mon4onng Wen(s1 Nor wells Sod Bonn apt W.V. Geotechnical <br /> ..Oul-OrSemce Well ni<I <br /> Pump <br /> Rlfrvlce Well Renewal 7 Cross-Connection Repair <br /> ew Pum Pump ReRlaceme t Pump R>pa" 'l Rahe Well= <br /> CONSTRUC- <br /> hitting Method-Mud Rotary _ Air Rotary .Auger Cabe 7.,0, U Ppsh Point _ Other <br /> :aposed Well Depth - ' it Excavaton i - <br /> _ -� i^m­+•ter I Open Bottom .•6 Gravel Pack/Gravel Size in diameter <br /> ConductRr Casing in diameter ! Cond:c^r rasing Depth ft <br /> ell Casing Diameter_ n Thickness!Gauge/ASI"M Schell i Slee) vfPlastic t'Stainless Steel f-Other <br /> rout Seal Depth R I Neat Cement(94 Ib baa 5 IP ria!water) 1i'Send Cement /J. sack m!xA gal wale, <br /> Bent-fte(20%solids) Other <br /> cut Placement Method,v Pumped -Free Fall i Other p Belardanl!Accelerator(name) <br /> PEDESTAL Installed By4'Driller Pump Contractor piper <br /> .Concrete Pedestal'_Dimensions Width it Le^nih R Thiele in ^Christy Boz -Stove Pipe <br /> PI/Me .Submersible-,Turbine Other Hi' Pump Set ft Sland'ng Wate Levet <br /> 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK-LLL BE DONE IN ACCORDANCE WITH SAN <br /> JO AQUIN COUNTY ORDINANCES.STATE LAWS.AND RULES aNO REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MINIMUM 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED - TITLE <br /> DATE ' <br /> low <br /> I ( I J t <br /> a � <br /> iJ \ <br /> 1 � <br /> 1� J <br /> f C� <br /> L <br /> r - <br /> o <br /> _.TD WA RTMENT 115E ONLY <br /> l <br /> Application Accepted By _ Area Employee IDN---- r <br /> Oates _ X14 <br /> Grout Inspection By Dale SPECIAL Well Permit_ � � <br /> Pumo Inspection By WAIVER Receivpri <br /> 0J � <br /> CD <br /> O O <br /> Cl) <br /> O c0 <br /> W � <br />