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WELL/PUMP PERMIT <br /> SAN JoAwN Coumn ENvutormErrTAL San Tu DcrARTMM 600 EAST MAIN STRLrT-STocKTox CA9M-(201)M 342011EYEM <br /> NON-REFUNDABLE PERINUT EXPIRES I YEAR FRoM DATE ISSUED Y I;� <br /> Jos ADDRESS _ l0 9/Q i3o L 1 _��_ CITY21P_U��7 G G/�C'� 9s s `' <br /> CROSS STRESr � ( All-1023-13 366G1 PARCEL SIZE Jr <br /> 7 _ <br /> OWNr,RNAME G I _/1/ PRONE �f - <br /> Ow'NERADDREM �� ''` / 0 'CrrY/STATM/Ar <br /> CON'CRACCOA <br /> ��Lr/ GV_ar !r� PIVONE ci <br /> CONIRACTOR ADDRE� /`� ` S / `•+� CiTYMATMIM—(_�"f <br /> SURCONTRAC[Oft <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP,—.---- -----_—.__. <br /> LtcENsc ❑C-57 bl Cl D4)9 ❑Otho NUMBER 257 4 S 4 EXPIRATION DATE <br /> GE0GRArMCA1.INF0RatATtoN: Coordinates X_ Y Township_ Range Section <br /> In-rsaDED Usx 13Domestic/Private ❑Irrigation/Agriculwral ❑Industrial ❑Walt Quality Monitoring ❑Soa Samplu4characterivuion <br /> ❑Public Wager Systrnt -- <br /> If diRamt tom Oarocr. Woe[S)aRm N..c ('aaract Nawc a Pleoc Number <br /> TYPE OF WORK ❑New Well ❑Replacement Well ❑Well AlonationlModificalion ❑Test Hole ❑Other _ _ PAVh NT <br /> ❑Mowtor6tgWell(a) rambcrs[.e111 ❑Soil Boriug(s) aaabernfbtriey ❑Creotechnical mmbrio(bor,oge RF <br /> �► <br /> ❑well Destruction ❑ -Of-Service well 13rn <br /> Out-Of-Sicc well Renewal cie1 V eD <br /> ❑New Pump ❑Pump Rpissectnent, Pump Repair ❑Cross-Caldxtion Repairv�� <br /> WELLCONSTRLcrM 0 2019 <br /> Drilling Method ❑Mrd Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Pout ❑Other _.... <br /> Proposed Well Depth R Excavation m diameter ❑Open Bottom ❑Gravel Pads/Gravel Sae__in di.mn8A J <br /> ❑Conductor Casing in diameter / Conductor Casing Depth tl V1ROV/N co Y, <br /> Wall Casing Diameter—in TltidcnesslGnugeIASTM Scheel ❑Steel O Plaagic ❑Stainku Steel ❑Other n NMENTAL , r <br /> Grant Seal Depth _R ❑Neat Cement rye/b bag/5-1OSW water) ❑Sand Cement ruGt mer!7 got!water DEPART <br /> ❑Benwnite(20%solids) ❑Marmfecouer Spec%solids_% Name ❑Specs on File ❑Specs Submitted MENT <br /> Grant Placement Method ❑Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(rwtte) <br /> PEDESTAL. Installed By ❑Driller ❑Pump Contractor ❑Other._._.____. <br /> ❑Concrete Pedestal Dhnensisna: Width_fl Laegth_R Thick in ❑Christy Box ❑Stove Pipe <br /> PUMP ❑Submersible ❑Turbine ❑Other HP Pump Set_-11 Standing Wager Level ___._R <br /> WELL DrmstverroN ❑Open Bottom ❑Gravel Pack ❑Uncased ❑Other <br /> Well Diameter—in Total Depth it Depth to Water 0 ❑Casing to be Perforated from R to R <br /> Seating Material ❑Nat Cement(94 lb bag/5-10 gal rwer) ❑Sand Cement—__-sack mit 17 gni water ❑Bentonite PeRas <br /> ❑Bentonite,(201%solids) ❑Mmackturcr Spec%solids % Nara ❑Specs on File ❑Specs Submitted <br /> Phoemeet Method ❑Pumped ❑Free Fall ❑Other.— <br /> ❑Complete with Mushroom Cap (t below grade ❑Complete to Existing Surtax Pad <br /> HEREBY CERTIFY THAT i HAVE PREPARED THIS APPLICATION AVD THAT THE WORK WILL BE DOME 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 WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORMERS <br /> iZ/0.NN( V�C�)'CiC�E RFC;' <br /> SlG1VE /x/A"iTLE_����'• ��� DATE <br /> AVE D <br /> 9 2019 <br /> NTAL HEALTH <br /> SERVICES <br /> AR NIT U <br /> Application Accepted By tc / A <br /> reaEmployee <br /> Grout Inspection By Date r Well Permit <br /> pump lnspectionBy Date ►� •W .+�1 0 WAIVER Received <br /> Desmsctiae Inspection By. Date Cenatmes ed Well Depth R <br /> COMMENTS -- <br /> PE SC Received Angst PermW -- <br /> Codes Info ad Dalt Service rear NIaYdee# Wed HN <br /> O W <br /> EHD 43-M-006 WEB we11 Permit Ind Us!arirrm d- <br /> 9111/2007 <br /> g <br />