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R f�j&W Pra�ec+ A g9y3. y.o-;o.oj -i17'/ 'J7 t I <br /> WELL / PUMP PERMIT <br /> SAN JOAOUIN COUNTY ENVIRONAIENiAL HEALT4 DEI-ARTNIFNT 600 E.isfaln Street-STocxfoN�02 - (209)468.3420 <br /> 'ON-Rt!u,4DABLE PERMIT C :%LL(209)953-7697 1-1.111 INSPIJ HONS EXPIRES I YEAR FROM DATE I.SSUFD <br /> JOB ADDRESS Cbz 1 ,AM&A,261.1 VQ= A*PK CITY/Ltr MqVr1T'e1%y% CIOV SJ-e 1 A <br /> CROSS STREET Y1 __APS <br /> 1 'If4-dao-0' .,_PARCEL SIZE~'j 1g A­LAND USP.APPLICATION 0 _ <br /> OWNER NASI[ <br /> �SPI� Mon. HW <br /> O,jSG (- PHONE <br /> OWNER ADDRLss J,SSO Sh�o>, ct.Jer D t-"vt CITY/STATEfLIP ��1/fA�t1�G ' CRI 'Nor <br /> CONTRACTOR LfJGEO �21rggr26-o'W PHONE <br /> CONTRA CI'ORAADRhtiJ Sw N• wl'ems-+ qoe, 5fe. A CITYNTATFJZIP <br /> SL'BCON-MACrOR �n(@st CaafrSE tZ p rd V-,GL�A 0 r'1 r"O%'E11 '153;40 <br /> 3 <br /> .%VM.%'TRACTOR ADDKF.SS `•� Wx 133 CITTYrIiSTATIYZ1P 66t0-'d A 153r� *t <br /> LICENSE XC•57 0 C-61 ❑D-09 Ll Other NUMBER E"IRATroNDAY'>;• 113)/"F+p ,V� <br /> GEOGRAPHICAL INFORMATION: Coordinmtes X Y Township Rr..age Sccllan <br /> INTF.NnRDUsp 1313omestic/Privatc ❑Irrigation/Agricultural C1 industrial O Watcr Quality Monitoring Soil SamplinglCharacwt zanon <br /> 11 Public Water Svstem <br /> If differ.nr from(lwnn" —��it�r,yslen, am. .urysct Naam re Phone Numbu <br /> "YPE UP WORK Q New Well O Replacement Well ❑Well Aiteration/Modificatirm O Other <br /> O Monitoring Well(s)_v�M of wells AS011 Roring(s)10-757 Mefbvrina. Cl Geotechnical enfbomW C <br /> D Out-Of-Service Well ❑Out-Of-Seryice Well Renewal ❑Cross-Connection Repair <br /> EJ New Ptimp d Pump Rc lacemcm O Pump Repair <br /> IVE11. ONXrR,ir TION <br /> Drilling Method ❑Mud Rotary D Air Rotary .Auger O Coble Tool ❑Push Point ❑Other <br /> Proposed Well Depth /a-30 n Fxcavatiun 4 in diatncter ❑Open Bonom ❑Gravel Pack/Gravel Size in diameter <br /> ❑Conductor Casing in diameter / Conductor Casing Depth A <br /> Well Casing Diameter in ThicknessKrnuge/ASI M Sched ❑steel 0 P�Lstic ❑Slainless Steel 0 Other <br /> Groat Seal Depth ft Neat Ccmen(,94 fb bag/S-10 gal M,urer) 0.Sand Cement ,rack our/7 gal water <br /> O Bentonite(20°/.solids) ❑Manufacturer Slee%solids °/a Name _ 4 Specs on File O Specs Submitted <br /> Grout Placement Nlelhod ❑Pumped Free Fall Other ❑Retardant/Accelerator(name) <br /> metsral. Installed By ❑Driller EJ Pump Coruraclor ❑ Other <br /> _ D Concrete Pedestal Dimeaslons Width ft L.en hh ft Thick in IJ Christy Box Q Stove Pipe <br /> t'M.- ❑Submersible O Turbine ❑Other HP rump Set R Standing Watcr Level R <br /> 1 HEREBY CERTIFY THAT I RAVE PREPARED TIIIS APPLICATION AND TtIAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CFR'CI;f-V 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 COMPENSATION I.AWS- <br /> NiININII'M Z! 110t;R ADN'AN(.'E N'O.'IC:: REIIIRF'D FOR INSPECTIONS <br /> S1GNF11 '11= _ DATE 8� 1 Joyj' <br /> 13 � <br /> um:t�tTlt�; <br /> Uji, <br /> MD <br /> sm. <br /> 49 IN <br /> 40A U L NTY <br /> Application Acceptc2i.8y / ...1 UaiOr Area Employee IDM <br /> Grout inspection d ! ❑ SPECIAL Well Pernift / <br /> Primp inspection By _4� llute ❑ WAIVER Received <br /> Constructed M10 lypth D <br /> COM TS �� <br /> PE SC 1:!JV <br /> ived Check#/ Amoral Permit! <br /> Codes Info CashRemitted Date Service Request M Invoice# Well IL�+1 <br /> we1L PVMP r-M%(TT <br /> tmnom <br />