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__ _FILE COPY <br /> WELL/PUMP PERMo4EWESER AVE 3 FL-STOCETON CA 95202-(209)468-3420 <br /> N <br /> SANJOAQIIN COUNIYEPYIRONMENTAL HEALTII DEPAIlTME6r y <br /> CALL RB9)95J-7697 rola INNPLC-ESO?N EXPIRESI YEAR FROM DATE ISSUED <br /> NON-ReruNDABLE PERni1T <br /> � D clry/Ln• -` <br /> 0 <br /> JOO A110RYSE TT 0//rT OO I-I)nSZ- /PARE!:LSI%EZ�f�LAND DEE AYI'LIC/.TIONN <br /> PRONE <br /> CROSS STREET <br /> . <br /> OWNERNAPE CMYI$TATErLIP�♦y��/�(J—�/ ' <br /> QNNE0.ADDRESS <br /> r <br /> CONIMCfOR CITY/$TATFIZIP <br /> CONIMCtO'ADDRESS PIIONE------ — \5) <br /> $UBC'ONE0.ACT0� •• N D- CITYIST(o6 �Z v1 <br /> NVa1RER 9 ENPIRATIONDATE l7 <br /> SVDCOMRACTORADDRESS $c<Iian� <br /> OGfiI ❑D-09 ❑Other�� Township_— Ranges <br /> LICENSE C"5] Y— <br /> GEOGRA%IICALINFORMATION: Caardh...lniBaliONABncuI1 Industrial <br /> Mer Quality Monitoring ❑Soil Samplinp/Chamcterivtion <br /> I:TENOED UEE ❑Dmneatlr/PriWle❑ nun •me or a um r <br /> Public WamrSystenn ream a <br /> ImMnmrto.m me 13 Test Hole ❑Other <br /> ❑Roolaccme'd Wall ❑Well AlterRliodMadir'u`" n verlwnsp ❑Gcusechnical <br /> TV r FNORE [3 NEW Well infWells ❑$oil 8.6.91) <br /> �IMonimrine WclIRI ce Well ❑OuiAf-Xrvice Well Acnewal <br /> p Pa.out- Rcair ❑Cross-Connttticn Rc air O% <br /> EI$/� ❑wenVealmain" ❑Pum R air ��r�•'��+"-_� IIS—� <br /> ❑New Pum ❑Pum Re laccmce, x//30 Push Point- r <br /> BAIMar <br /> wage, ❑Cable Tool --nwc <br /> WELi"g Met od E3 M O Air Rotary W` ❑Open Bottom C1 Gravel Pack/Gavel$is <br /> Drilp..d Wall E3 Mud Rou3ry E.RaWa n in diameter <br /> /5S © D/�// <br /> 1QL n 7 <br /> ProPamd Well Depth in diameter I ColMuctor Casing Depth�O$uinless Steel <br /> ❑ naterConductor Casing ��/� ❑Stttl "`''ll pP�ld a0 Sp irl'Igalwod <br /> 2 in ThicknaslGaugalASTM Xhed SSC rr) ❑Sand Ccmcnt�� <br /> Well Casing Diameter kNoa,Cemenl(94 lb Avg/J-/O gu ❑Specs on Pile ❑Specs Submined <br /> r Grout Seal Dcplh_110 it !P'- /selids—% Nam' <br /> ❑Bentonite(20%solids) Cl ManuFedurtr Spec°• 0 Relardent I Aceekramr Cname) <br /> Grout Pla¢ment MHhnd umpEd ❑Free Fall ❑Olhm��— 0Other <br /> 13 Driller ❑Pump contractor R Thick in 0 CM1ris1Y Box ❑Stove Pipe <br /> Installed B fl Lengthy D <br /> PEDESTAL 1� Widths Pump Xtit Standing Wamr Level <br /> ' - <br /> Concrete Pedestal Dimensions: 1]O,hcr HPC <br /> ❑Submersible ❑Turbine ❑Other fl <br /> PUMP ❑Grovel Peck ❑Uncased fl to_� <br /> ❑Open Bodam R Depth m Wam, fl ❑CasinB to be Perforated from <br /> WELLDFSTRUCrton in Toul Ocpth Buck mix/]gal rasa, ❑eemonite Pdlers <br /> Well Diameter— alwmer) OSand Cement�� 0Spawn on File PSptts Submitted <br /> Scaling Material ❑Neat cannot(94 IS be,/J-109 % Namc— <br /> ❑Benlonuc C20%solids) ❑❑Free Fee Fall ❑Othetheaeturtt$Ptt Y s <br /> r ❑Complete to Existing Surface Ped <br /> Placement Method 0f.Pcd Abelow grade <br /> ❑Compicto with Mush,00m Cap <br /> 1 HEREBY CERTIFY THAT 1 IIAVE PREPARED THIS APPLICATION.AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT i Ah11N COMPLIANCE WITH ALL <br /> JOAQUIN COUNTY ORDINANCES,STATE LAWS•AND RULE$AND REGULATIONS. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE 18 <br /> WORK,R$COMPENSATIONLAWS• OCT.a L <br /> MINIMUM 24 NOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONSDATE <br /> TITLE <br /> $ICNI <br /> I <br /> DEPART us D Am EmployeelD <br /> •••VVV {{��� <br /> ApPlDate p SPECS Well Permit <br /> Gm,Accrytd By .-0u - <br /> Grout insPation BY ` ❑ WAIVER Received <br /> �l <br /> f <br /> Pump Inspection DY Constructed Wall Depth <br /> /D pcnmction Insptttion By <br /> COMMENTS <br /> '. Permit/ InvolceM <br /> Well iD8 <br /> GheekBl Amount- Data Xrvlee Re uesl B <br /> .� PE SC Received Remitted <br /> ...i Codes Into <br /> M/3TER WATER WELL al <br />