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WELL/ PUMP PERMIT <br /> SAN JOAQl7N COON IV EWIRONMENTAI.HEAL1 H DEPARTMENT 304 F,WEBER AVE 3"FL•STO('K I'ON CA 95202 -(209)066-3020 <br /> NON-REFUNDABLE PERMIT ( \1.9 .'O'a)�� '(/y'{/I IYit hw1.r l t"" EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADUNFaS 11tRRR��� CITVfZIP <br /> CROSS STREET C/- ' <br /> Z O O PARCEL SIZE 'r LAN IISE APPLICw 110N✓<� APN <br /> OwNER NAME PHONE <br /> OWNER AIIURLSS CII VISTATL/ZIP <br /> —� <br /> PRO <br /> CONTRACTOR _ ' <br /> CONTRAC roft ADDRICSS - _ ' (� _ C'ITV/STATEl7.IP - G <br /> ShBCOKTNAC'lOR HOVE U <br /> SCBCON'I'RAC'1'OR4BDRF.S8 __ CITY(SIA'IE/ZIP <br /> LICENSE e� 57 C-61 ❑D-09 ❑Other NLMBER EYPIRATION DATF. <br /> GEOGRAPHICAL INFORMATION-. Coordinates X V Township Range Section <br /> Ir(TENIIF.D I'SF. ❑Dimeatic)Prvate O ImganoNAgricuhural ❑Industrial ❑Water Quality Monitoring ❑Soil SamplinglCharacteriaaiion <br /> ❑Public Water System <br /> 1(difrerem r-0— n—yor.Nome <br /> 'F1'PE OF WORK ❑New Well ❑Replacement Well ❑Well Alreranon/Mudilication ❑011ier —_. s MMrirya <br /> X i.f Mrin� <br /> 13 Monitoring W'tal(s) ti of wells []Soil 13onng(s) ❑Gewc'h.'�al <br /> ❑ Of-Service Well ❑out-of-Service Well Renewal ru d'unn tiuv Repfitr� <br /> Ncw Pum ❑Pum Re laccrnent ❑Pum R air <br /> WEI.I.Consral;c'nuN <br /> Drilling Method ❑Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tuol ❑Push Point ❑Other <br /> Proposed Well Depth ft Eacava ion in diameter 0 Open Bottom ❑Gravel Pack;Gravel Sire <br /> ❑Conductor Casmg _m diamsna ) Conductor Casing Dcpth <br /> Well Casing I)iUMCICT _in ThickneWGaugWASTM Sched_ ❑Steel ❑Plastic O Stainless Stecl ❑Other <br /> Grout Seal rfepuh R ❑Neat Cement t94?h Wilt.5-10gaal wwer) ❑Sand Cement sack mie i gal water <br /> ❑Bentonite 00%solids) ❑Manu111CU rcr Spec%wilids,% Name ❑Specs on Fllc ❑Specs Submreed <br /> Grout Plaremeol Method 0 Pumped ❑Fres Faii ❑Other O Retatdsnl I Accelerator(name)__- <br /> PEnEaTAI• Installed By ❑Unller ❑Pump Contractor ❑ Other <br /> Cl!; erste Pedestal Dimensions:Width R Length R Thick in ❑Christy Bos ❑Stove Pipe <br /> PItMP Submersible O Turbine ❑Other 11P Pump Sae R Standing Water Levcl R <br /> I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AID THAT THE W'OR WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDINANCES,STATE LAWS. AND RULES AND REGULATIONS. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COM NSATION LAWS. <br /> +jtlM1t 11? HOUR kIl%:�'�(f.�illl'Ic I: t}I I a)i OR <br /> SIGNED , - ' r TITLE DATE <br /> El� <br /> I <br /> lip 7 # <br /> LL-1 I I <br /> ED 71111111 <br /> P A T M E N T U E O L V <br /> Applicalion Accepted B7'� l� Dat, Area._ fimpl(vyce ID0 <br /> Grout Inspection By - __ I)ate .( ❑ SPECIAL Well Permit <br /> l ❑ WAIVER Received <br /> Pump Inspection Bf!,� -. ..---- -- — -- Dale_ .. -- <br /> Constructed%ell Depth __. _ It <br /> COMMHNTS <br /> PE SC Received .•'Ch. 1- unt Permit/ <br /> Uate Service Re uest p ln,oice X -�- Well IDM <br /> Cod Info B __"Cish R,mllted - — - <br /> - <br /> N'El.l PUMP PEKMiI <br /> END 4)-0:C("• <br /> 1:T:20a5 <br />