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CONTRACTOR ADDRESS
<br />OwNER Anmoss a1,12.14_11_13
<br />CONTRACTOR V P go
<br />P t 13t)
<br />omsc NaMeIn Pliaire-ATZGer
<br />
<br />0 Public Water Sytem
<br />
<br />differed rnfm Owne, Water System Name
<br />ei• ,.n WELL! PUMP PERMIT
<br />SAN-JON:711N COUN1 Y N IRON MENT AL ISEALTR DE POO M ENT 304 L WEBER AVE 3"" FL- SToacton CA 95212 - (204-468-3420
<br />.40N;-REFLNDABLE PERMIT CALL (209) 953-7697 FOR I \SP CTIONS EXPIRES I YEAR FROM DATE ISSUED
<br />0 r JA L
<br />St RCONTRACTolt
<br />SCKOATRACTOR ADDRESS CITVISTATErZAR
<br />Jon ADORE-S5
<br />CROSSSTREE7 0
<br />OWNER NAME d sfit \\N PHONE -51/- 7/53
<br />CirrigrATETZte A e 047 ?
<br />PitoNT
<br />CirviSTATE/Zip (alt- CA el 1 7 a-3,9
<br />LICENSE )5(C-61 D-09 0 Other 1LMBkK D±i.11.383 EXPIRAIION DA TE 0q--
<br />GEOlilLtieRICAL IMORMATION: Coordinates X Township _ Range Section__
<br />PRONE
<br />Ct nate i) 95.2X)
<br />007- 12M " 6) PARCELSlef ',I:lei-CS A PN
<br />INTENDED USE .<Dornestic/Private U IrrigationiAgricultural 0 Industrial 0 Water Quality Mcnitonng 0 Soil SamplingiCharameriyation
<br />TYPE OF WORK >II-New Well 0 Replacement Well 0 Well Alteration/Moditicaiion 0 Test Hole 0 Other
<br />0 Monitonng Well(s) 0 number of wells Soil Horing(s) '"rnbc` Of bOnngs 0 Geotechnical
<br />Out-Of-Sc-mice Well Renewal 0 Well Destruction 0 Out-Of-Service Well
<br />nurnoer of Ixatrgs
<br />Im 1 1 II 111111111LI ..: z-, ! if' ' ,
<br />nu iiiiiiiiiirilliiiiiiiiiiiiiii 4
<br />
<br />allgillilIPMF, F. ARTMENT IIJ ,. )111/
<br />Applies ion Accepted By 'Al- _uate # di 0 Area ____44:;._ funployee IlLtht 51V, ti(7 1
<br />Grout Inspection
<br />Pump Inspecti Bv
<br />Date
<br />
<br />Dae-I---------e:Y79
<br />0 SPECIAL Well Permit
<br />0 WAIVER Received
<br />Destruction Inspoetion By <ittis..tri5te--; Cel.I irillh c-,3.....,
<br />COMMENTS - ,-,,,,.,-71;,.--e, , ---,zee- r•re
<br />,• . I
<br />Ncw Pump 0 Pump inerment 0 Pump Repair 0 Cross-Conneetiun Keppr
<br />WELL CONSTRUClUON '
<br />DriRing Method A Mud Rutury Fl Air Rotary 1:1 Atiges, 0 Coble Tool
<br />Proposed Well Depth 02 /20 ft Excavation / a in diameter .
<br />0 Push Point 0 Other
<br />0 Open Bottom Ieel Pack /Gravel Size lief in diameter
<br />0 Conductnr Casing in diameter / Conductor Casing Depth
<br />Well Casing Diameter 147 in Thicknes.s/Gauge/ASTM Soiled CIS ,)-4313
<br />II
<br />0 Steel )plastic 0 Stainless Steel 0 Other
<br />..-r-irSand Ccnynt1 ,sock mix / 7 gal water ..., Groot Seal Depth __ /CIO R 0 Ncat Cement (94 lb hug ( 5-1(1 gal water)
<br />0 Bentonite (20% solids) 0 Manutactuier Spec % solids % Nome CrOi4t1fr t t— VW' 0 Specs on Fie 0 Specs Submitted .
<br />Grout Placement Method teKniped 0 Free Fall Li Other V 0 Retardant i Accelerator (name)
<br />PEDESTAL Installed HI, 0 Driller D Pump C.0n1Molor El Other
<br />,k(Concrete Pedestal Dimensions: Width _Hr ft Length fl Thick l() in 0 Christy Box 0 Stove Pipe
<br />My XSubrnersible 0 Turbine 0 Other HP Purim Set &ea) ft Standing Water Level ,/,;26ft
<br />WELL DESIRLCEION 0 Open Bottom O Gravel Peck 0 Uncused
<br />Well Diameter is 'rota( Depth 11 Depth to Water
<br />0 Other
<br />fl 0 Casing to be Perforated (rote 0 to 11
<br />Seating Material 0 Neat Cement (94 lb bag 1 3-10 gal woler) 0 Sand Cement
<br />0 Bentonite (20% solids) 0 Manufacturer Spec % solids %
<br />cock rots i 7 gal water 0 Bentonite Peltets
<br />Name 0 Specs on File 0 Specs Submitted
<br />Placement Method In Pumped 0 Free fall 0 Other
<br />Cl Complete with Mushroom Cap it below grade 0 Complete to Existing Surface Pad
<br />I HEREBY CERTIFY 'MAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN
<br />JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT Nisi REQUIRED LICENSE IS
<br />CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALI,
<br />WORKERS COMM NSA•IION LAWS.
<br />MINI /M2,11121.1 MANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 95 7697
<br />SicsED TITLE 2rtfe-tdeetl+ DATE . ir
<br />PE"-.
<br />Codes
<br />SC
<br />Info
<br />Received
<br />Be
<br />C_ C.L16.16/
<br />Cash
<br />Amount
<br />mi Remitted Date Date r i
<br />It nest ,,,,;,20..r2icecir -,....e UtgeVa'a,
<br />1% gio..,-z-L., 7537-- 9-2-5— 7 17 5000 3464 /'''0_,„ ,izo , .., I ,.....".-- .,..-d
<br />.,--1 - — , — • -s' ..„.,,,,... •-.
<br />51) c/. -G.{- -.,.---• --e.,,---- _
<br />''- '" - 4
<br />El ID A3-02-9 ., ,,e!k ER Wrii PCRMIT
<br />„4./6i2002
<br />'—ec? VitIUGV 33.1c
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