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WELL/ PUMP PERMIT SAN JOAQL•IN COuNrY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3"FL-,STOCK MN CA 95202 -(209)468-3420 NON-REFUNDABLE PERMIT C 41.1 ._IN3j V•;:-^i¢I•'11,14 I\�j.r I I•'", EXPIRES 1 YEAR FROM DATE ISSUED Jus ADDKESS CITN IZIP oy CROSS STREET -/� (( _LtA�FN p 2 r'O "---PARCEL S1T.L4 iKC D 115E APPLICA1I0N p_ OWNER NAME �� 1�/LI_n I/r G 4444 [d!)'(1` PHONL OWNER AnuRLss C11 VISTATE/ZIP CONTRACTOR PHO' CONTRACTOR ADDRESS --�� l'ITYlSTATFILIP f /F SOBCOtiTRAC"TOR HONF.�__ SVIICON•TRAC'IORe BDRESS - CII'Y/SIA'IE/ZIP LICENSE f7 C'5? C-61 ❑D-09 O Other NLMBER EXPIRATION DATF. GEOGRAPHICAL INFORMATION'. Coordinates X V Township Range Section I.VTENDEn t:SE ❑Domegtic+Private 0 IrngatlowAgriculmral O Industrial 0 Water Quality Monitoring ❑Sod SamplingiCharacteriution 0 Public Water System __ tf dtfft,e,from ). foci seem Name ac•.Tame nr P me Num r TYPE Of WORK 0 New Well 0 Replacement Well O Well AlterauonlModilication O Other ❑Monitoring Wetl(s) Not'wells 0Soil Burt g(s1 Y"rnnr;ng, ❑GeolvOunical — aofharinp ❑Cd(or-Scrviec Well O Out-OT-Servim Wcll Renewal iu -Conn •tiuu Re e'w Pump Cl Pump Replacement ❑Pump Repair WELL CONSTRUCTION Drilling Method ❑Mud Rotary ❑Air Ratary O Auger O Cable Tool 0 Push Point ❑Other_--_ Proposed Well Depth A Excavaoon in diameter O Opco Bottom 0 Graxcl Pack.;Gravel Sim in diameter 0Conductor Casing _indtamewt , Conductor Casing Depth A Well CasinR Diameter_in ThickncW0auWAS1'M Sehed_ _.. 0 Steel O Plastic 17 Stainlcm Steel ❑Other Grout Scat r)epth fl ❑Neat Cement 1941h bog. f-10ga1 avnrr) ❑Sand Cement rack mix;7 gal water ❑lientunite 1206,_,solids) O htanuracturer Spec%solids_% Name O Spms an File 0 Specs 8uhmined ,Grout Placement Method O Pumped ❑Free Fail ❑Other 0 Rciardanl I Accelerator(name)-_-_ — t' t. Installed By ❑Drller O Pump Contractor O Other ❑C crcie Pedestal Dimensions:Width R Length ll Thick in O Christy Bus ❑Stove Pipe PIMP Submersible O Turbinc O Other IIP Pump Sel_ ti Standing Water Level 11 1 HEREBY CERTIVV THAT I HAVE PREPARED THIS APPLICATION AID THAT THE WORII WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTV ORDINANCES,STATE LAW'S, AND RULES AND REGULATIONS. l ALSO CERTIFY THAT MV REQUIRED LICENSE IS CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS COM NSATION LAWS. NIINI 2}`HOOR 0%AN(F.N0FIC'F 01.I 1)FI IR I�Nlllt. I ION SIGNED Ir f'4 TITLE , DATE(- _ I I A7 i LJ T D 'PA TMENT U E O Ll' Application Accepted Hf �l Date � Arca I•.ntplo)cc IDN Grout Inspection Hy _• Date _ ❑ SPECIAL Well Permit y i Pump lnspa+tion By'z ,i �_ `'.--__---- _ -... Dale _. ..._ O WAIVER Received Constructed Nell Depth It COMMQNTS >.'h , 1_ L` eel-- f' 1 !/( — - PE Sc Received Amount Date Permit/ IlryN oice N Well II C Info B "C-ash Remitted _ Ser0ce Re uesr k CHD43-02.0% w•ELI PtlMPP1ltmll 111,20X!