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_._1 1a► � ►3 <br /> t <br /> WELLIPUMP PERMIT <br /> SAN JOAQUIN Cautrt F-NvtLONNENTAL HEALTN DEPARWEAT 1861t EAST HAZELT0.1t AVENUE-STOCMN CA 95206-(209)468-3428 <br /> MON-Re-FUNDABLE�P+E/REMIT �` CALL 209 953-7697 FOR INSPECTIONS � c1�EXPI:fRES 4 YEAR <br /> �FROMCDATE WUED <br /> LA <br /> JOS ADDRESS -1—P Or TI CITYCLIP JTD/.L�.TUI� �J Z r m <br /> a <br /> CROSS STREET Al <br /> `ril lu APN le)("ZbQ':�VIPARCEL SIZE LANDUEEAPP'UCA-nONN# G <br /> OWNERN"E �J2 I V/ A 1 Ci/ YtAP'-�ID /[ PHONE f•to7�/y��IS 0 <br /> VS <br /> OWNERADDRESS I !�Z �• �/SLfV C(TYISTATE173P- COY/�!!jS <br /> CONTRACTOR Q rOA' dYl 'J. PHONE 7-D9.1-15. (B.t-7t <br /> CONt'RACTORADDREea VA- & , CA _ 5MQ <br /> SUBCOUrRAOTOR PHONE <br /> SUBCONTRACTOR ADDRESS CCiY1STATEI2atP p <br /> LICENSE D CS! C-61 17 D-09 D Other NUMBER D—J 22 1(/ MMAMON DATE C 1:9) -2O ZLQ— <br /> Dom=WELL SAMPLING:0 General MfnerallColilomt Bacteria(4391)0 Dibromoohloropropan6(4392)0 Arsenic(4393) <br /> INTEMEDUsE >(DornesSdPrivateFirrfgataVAgriadtural Dindustrial uWater Quality Monitoring 0Soil Sampling/Charactedzation <br /> D Public Water System <br /> I It dllterart bmrt Owner: Watereystam Nam* Contact Namear Phone Numbs <br /> TYPE OFWoRx C New Well U Replacement WSJ( C WeliAheration/MDdFBcation D Otter <br /> O Monitoring Wells) #ofweils 0 Sal Boring{s) Aorbmdng D Geotechnical rotborings <br /> p Out-Of.Senice We11 ❑Out-Of-Service Well Renewal p Cros"omtection Repair <br /> >QNewPump0 P-mp Replacement O Pump Repair iT Raise Well Casio <br /> WELL CONSTRUCTION <br /> Drilling Method 0 Mud Rotary 0 Air Rotary C Auger D Cable Tool D Push Point ❑ Other <br /> Proposed Wed Depth lt E=vadon in diameter ❑Open Bottom D Gravel PaNNGravel Size in diameter <br /> 0 Conductor Casing in diameter I Conductor Casing Depth 0 <br /> Well Casing Diameter—fn Thickness/GaugWASTM Schad D Steel C Plastic a Stainless Steell C Other <br /> Grout Seal t lepth It O Nest Cement(94]b bagl5-70gal water) 0 Said Cement sack mix/7 gal water <br /> ❑Bentonite(2D°A solids) D Other <br /> Grout Placemetrt Method 0 Pumped ❑Free Fag p Other Li Retardant f Accelerator(name) <br /> PEOESTAt Installed By D Driller Cl Pump Contractor 0 Oilier <br /> p Concrete Pedestal❑Dimensions:`Arhith ft Length. R Thick in 0 Christy Box t;Stove Pipe <br /> PunnP Submetslblec Turbine D Other HP Pump Set !UA 6 fL Standing Water Levetfill <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK Will BE DONE IN ACCORDANCE WITH SAN <br /> 10AQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS. I ALSO CERTIFY T'r1AT MY REQUIRED LICENSE lS <br /> CURRENT AND ACTIVE WITH THE FORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COM At WS. <br /> bA1Nl H NNSANOTICE REQUIRED FOR WSPEC`CIO -PLEASE CALL(209)9.53-7697 <br /> SIGNED ^',' TITLE a V DATE <br /> Awr <br /> + EQE1VE® <br /> V 2 7 2010 <br /> AQUIN COUNTY <br /> 1NftqRONMENTAL <br /> DEPARTMENT <br /> EP TMENT L E O LY <br /> Application Accepted By Date Area^'a Employee IDQ <br /> Grout Inspection By Date ..PEGAL Well Permit <br /> Pump Inspection By Date i7 WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS. <br /> PE SC Recalved Check#/ Amount ate Permit! lnvolee# Well ID# <br /> Infix 43 A Cash matted Service Re uest# <br /> EM 43Aa FW$od 41S419 WM-L/PUMP PERMfr <br /> !vl�z344 �� <br />