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WELL / PUMP PERMIT G dos 3s7 <br /> SAN JOAQUIN C;OLNTY E�VIRIINMZNTAL IlEALTH DEPAKTMFKT 304 E WEHER AVE 3'°FI,-%1w.xTOS CA 4521)1 - (109)4t <br /> NOIR-REFUNDABLE PERMIT CAI 1.009 953-7697 FOR INSPeCTIms EXPIRES I rYEAR FROm DATE I <br /> JOB ADDRF55 Is S E tl L�� '—KAT CfrvlZIP <br /> CRO•CS STREET &I L ri A PN _ 3/S �PARCIL SIZE V!t�AN D UST APTUCATION h_- <br /> f��/f � <br /> Ow`1ER NAME rc-u.►IS . ,frs[1ne- _. -- PHONE rZ� <br /> OWNEIt ADDRISS _-,1_�l,R / k Crl'Y15TATTfGP JT/ <br /> C:OTFRA(TOR <br /> CmrrmcroR ADDREss gov, .. Frl� _ CI7Y✓STA1'tJZIP <br /> SlJBCON-11LACTOR _ - PHONE <br /> SUBCONTKA(TOR ADDRESS _ --- CrPY1STATVZIP - n(� <br /> LiCEN5E 57 ❑C-61 ❑D-09 [I Other _ YUMBf•R EXPItiATION DATT � 'V A/ <br /> GEOCRAPWCAL INFORMATION- Coordinates X V ._ Township RangM Seclion— <br /> INTLNDF.D LSE ❑Domestics rivate ❑Irriptiun-Ag.icultural ❑Industrial O Water Quality Monitoring dirsoil Satnpling-Characlmz <br /> ❑Public Water System___ — — <br /> If dLfltrenr flow.Owner: ower yetRT ttrne on0oct eme or PlatuC.u <br /> TYPE OF WORK ❑New Well ❑Replacen=t well O well AltenattonlMudifwcation ❑Othef <br /> ❑Monitoring Wclk(s) k of wells ❑Soil Aonng(s) - _ sof bonito �Gtwta finical 0 urMretnys <br /> ❑Out-Of-SM-ice Well ❑Out-of=Service Well Renewal O Cross-Cuttnec:irxr Repair <br /> ❑New Pump 0 Pump Keplacement ❑Putrr R it <br /> Wr.tl.CONSTMiRt 10N <br /> Drilling Method ❑Mud Rouiry ❑A:r Rotary- ONAuge.- ❑(.able Tool ❑Push Point ❑Other <br /> Proposed Well Depth Excavatiun in diameter ❑Open Bouom ❑Gravel Pack,Uravrl Size In <br /> ❑Conductor Casing __ , in diameter r Conductor Casing Depth ^ft <br /> Well Casing Mameter in Thicknes4kK_1auS&ASTM Sched_-._ ,_ ❑Steel ❑Plastic Q Stainless Steel ❑Other <br /> Grout Seal Depth ft ❑Neat Cement(Y4 1h&K/5-10 gal writer) 13 Sand Cement ,uck mix "+ I <br /> ❑Benemtite(1L1"o solids) ❑Maoufacturrr Spec%solids % Name .ST>ccs on file ❑Specs Sul <br /> Grout Placement Method [3Pumptx3 D Free Fall ❑Other ❑Retattlanl? c tnr amel <br /> Tom" Iwalled By ❑Dnl'.cr 0 Pump Contractor D Other - <br /> O Concrete Pedestal Dimensions;Width Il Length ft Thick in ❑Christy Boir ❑Stove PLl <br /> PUMP ❑Subntervihle ❑Turbine ❑Otho HP Pump Set ft Standing Water Level_ <br /> 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK %ILL BE DONE L\ ACCORDANCE VITT <br /> JOAQULN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. 1 ALSO CERTITY THAT MY REQUIRED LICEI <br /> CURRENT AND ACTIVE. WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WTI' <br /> WORKERS CO PENSATION LAWS. <br /> !V !M 24 HOL.R ADVANCE NOTICE REQ1.IRED FOR INSPECTIONS z (^ <br /> �• TIrI.e ,v C.t 11RW DATE -171.5105- <br /> ✓ +r <br /> SIGNED _ - - <br /> 4 1-4- <br /> AN <br /> tE <br /> 1 <br /> t <br /> 0 <br />