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WELL/PUMP PERMIT Q <br /> SAN JOAQUIN COUNTY ENNOSON,NCNTAL OTH DEPARTnmm' 304 E WEBER AVE P°FL-TOCKTON CA 95202-(209)465-3420 <br /> NON-REFUNDABLE PERMIT CALL 209953-7697 FOR INSPEC PIONS EXPIRES I YEAR FROM DATE ISSUED <br /> JOBADDExas41425' Sotrr�-I wE�('�t,�T^u u2 pQrJt cCr,/M, <br /> � 'e <br /> CROSS STREET Lt M1f M1f V ROia//�D ApN PARCEL SIM USE APPLICATION IJ <br /> OWNER NAM PLO-/ST'�z t?6TAT� / elWwl i3 w�Pxorre��i(fo�34-� - lo(e>(�(7. �` <br /> OWNERABBREss IOOI Z bTZce� CIIV/$TAIPILB SACRAM'iJ rte Cr>< �> O1Z <br /> CONTRACTOR LFZ l-kr=S/Ir C— FDIC-K6 PxnNE <br /> CONTRACTOHADDRESS 41552 17oJ4l.stt '6LVDI� O CrrirsrArviceI!W-AN rr6 ISAr-'/IC'/L `i�14 <br /> SUBCONTRACTOR CASC.s!-I�ti SJP-t L.L1e�IG, PHON]i IIY �Opy ' t l(,,,aI <br /> SDBcos"mcTo�RADDRass 31"z &ry G[_ cize- ..t> CM/STATE2@ 9A4`JC90 COP 0syJAICA eC`M <br /> LICENSE XV-57 MC-61 ❑D-09 ❑Other NO ER�]I�D t'a ExntanoNDATE Gl >p1 . 0(p <br /> GEOGRAPBICALINEOR IA1T)N: Coordinates X Y Township_ Range_ Section_ <br /> INTENDED USE ❑Domadc/Pnate ❑fingadon/Agdcultusal ❑lnduatrial Wa[er Queliry Monibdng ❑Soil Sampling]Chencterimtian <br /> ❑Public Water System <br /> Ifdi?ifmm Oun . aler Ytlgn me ca�art ®enc me wn <br /> TYPE OF WORK Pk4ew Well ❑Replacement Well ❑Well Altendon/Mexificadon E3 Other <br /> Pf Monibring Well(s) #of wells ❑Soil Bodng(s) "'b" au ❑Gemachnicd 'I"f tor., <br /> 11Out-0gService Well 13Out-04Servia Wall Renewal ❑Cross-Connection Repair <br /> ❑New Pmnp ❑Pum Re air <br /> WELLCONSTRUCr10N <br /> Drilling Method ❑Mud Rotary ❑Air Rotary ,'A(Auger ❑Cable Tool ❑Push Point ❑Other <br /> Proposed Well Depth I Z R ExcavaLon in diameter ❑Open Bottom ❑Grevel Pack/Gravel Sim in diameter <br /> ❑ConductorCasing indiameter / Condman Casing Depth ft <br /> Well Casing Diameter Z in ThicknemaGeuge'ASTM Sched 4-0 ❑Steel ❑Plastic ❑Stainless Stal OOther Py C: <br /> Grout Sal Depth4W ft (Neat Cement(94/hbog/J-/Oga/w .,) ❑Sand Cement suckmix/7galwmer <br /> Bentonite(2Msolids) ❑Manufacturer Spec%solids_°% Name ❑SpeNonFile ❑Specs SubmimR[ <br /> Grout Placement Method OdPurn,ed ❑Free Fell ❑Other 13 Random/Accelerator(name) <br /> PEDESTAL Immlled By nller ❑Pump Contractor ❑ Other <br /> O Concrete Pe astal Dimension,:Width ft Longlh ftThwk in ❑C6rhryHox Steve Pipe <br /> .— OSubmersible ❑Turbine ❑Other FTP Pump Sa ftSmnding Water Level ft <br /> I HEREBY CERTIFY THAT I DAVE 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 CERIIT THAT MV REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> A IMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> SIGNED TITLE Q on QDATE 9-/-0� <br /> ��a�J� <br /> DEPARTMENT SI�E <br /> Application Accepted By C�a`^esr Data qq4 11w 4DNLV Area Employee R)# qq7 <br /> Groutlospection By Date -L Db ❑ SPECIAL Well Perini[ <br /> Pump Inspection By Date ❑ WAIVERReceived <br /> Constructed Wall/ I <br /> Depth <br /> CONMAENTS-/s7 W _ IAA Rr" <br /> PE SC I Received ChecW Amount Date P°�tU Invoiceq Wel1IDM <br /> Codes Info B Cash Remitted Service Re uatp <br /> of D / Oso 4/G A Slaom S <br /> Efm auB.Nw w¢L euaP P9OGr <br /> 14]/fiw5 <br />