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WELL/PUMP PE%MIT .1[ r:\1}1}1''1111 ' SARJOAQt LN C0V%'rVE!MMORf1ENTALA£AL•i'J DEPARTNUN17 600E.4wr%1Az STxm-STOCKTOti CA9S202-(319)4fr8-34>4 �.�)��1`�II II VON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED Y Itlllr� 1fL'17�_U ` 'son AODItE55 i l�(�U/ N,��I,." CLMR. 07StZ1P�W &y A_ qL,[� wQ0bF D6 2oAQ �p CRoss STREET Ic r API L2l_?z,120-�� P.taceL S,zE�•04 Ow:.sERN.tME MC1 AC—S, -A PRose_a—39:3-1311 OwnERADDRM I/go(otp�IJ,G\CLr(,`1r-lA� aopz/ Po,�IX,1Tvs'r sr ,ww(sLB�'(/L�t(mrG ,/.�y/� �c}S� CosiluCToit ZTl71.J✓� W �£/�, �Fi]�� 1� n.... y,/ t e i—9-910 �.,[y� LL lei t\W A '� 1 w a CO\"tAKTTIR ADDRES6 l�,� �• il l�O 1M7,�_ CiSI'(STATF/ZIP� L�J s SUCCOKTRACTO)t / _ P110%E SUDCORIRACTOR ADORM CITTVfST.�%TT��E7A�r___,_ Lin n ❑C-5i C-FI ❑1}09 13 Other Nt:vtRER,,aj �Q"l Exxxtuo%D.tTE GE0Cf tPR,CALISFOR+tarso+: Coordinates X V _ _Township— Range Seatlea INTENDED I.ISE fLDoniestic.Private ❑briptiomAgricul4 ral ❑Industrial G W'aterQuality.Monitoring ❑So3 S raplincharacorliation ❑Public Woe,System_____ w itdifii=fr.:O.a:- TS�w..m�'aen. '- Ccazc�V-:m...x Ph—h¢dcr r/ T,'PE OF HORR G New Wall ❑Replacement Well ❑Well At.^ruion;.totliiSr�fon ❑fest Hole ❑Other— 0 Y��N� ❑Monitoring Wems) °1°k`aa:`I' ❑Soil BorDAs) r me:r•.rhmne. O Gcouxhoical a Well Destracdn ❑Out-Of-Service Wall' ❑Gut-Of-Scn ic:Well Ranawal ��a N°° O D -Viievi FMR.laccmcnt ❑ R. it ❑Cross-Cotutzeiron Repair WELL CoaSTaucrloN `r ?4?0 DrOn Method ❑Mud Rolaty� O Air Rotary ❑Auger 13 Cable Tool 4 Push Point 0 Other J Prepesed Well Depth ft Excavation—in diameter O Open Bottom ❑Gravel Park,Gravel Six—ill disa,ese OgQU/ ❑Conductor Caaing in diameter 1 Conductor Casing Depth _ft N "0 N CO Well Casing Diamoter—in Thickness!CrauSvASTM Sched ❑Steel ❑Plastic ❑Stainless Steel Q other `TN U�pgRNTq� Grout Seal D;pth ft C3 Neat Ccnrnt t941b bag: and 5-10 gal xwa) ❑SCemeru sack mfr;7 gal water MFNT 0 Beramno(2W6 solids) ❑?Aanufactu=Spec%solids_% Xan= Q Spres on Fila ❑SpcesSubmitted Groat Plaeemeat Metbed ❑pwnped ❑Frcc Fall ❑Other 0 Retardant:Acceloratm(name)� t PEPF-WAL Iaatalkd fav 0 r Mils 0 Pump Contractor L3 Other -- ❑Concrete Pedestal Dlmeadons: Withh_ft Lcuath_11 Thick in ❑Christy Bet 0 Sbme Pipe Pu?lP ❑Submersihic ❑furbine OOther HP Ji 2 Pump Set k0Q_ft SWttdiagWucrLr.d _0 WELL DEsr tucrtov ❑open Bottom D Gravel Pack 0 I;uccacd ❑Other t Well Diameter_in Tsai Depth` H Depth to Wats _ft ❑Casing to be Perforated from fi to It j Sealing Material Cl Neat Cement M 1b bag:S-tOgal wafer/ D Sand Cana: vack mL-[7 gal suer ❑Bentonite Pellet E3 Bettioolu:i20':%solids) 0 Manufacturer Spec:%solids so Kam ❑Specs on Fil: O Specs Submitted Placement Methed ❑Pumped ❑Free Fall ❑Other . ❑Comptelo witb.Mushroom Cap ft below grade, ❑Complc:e to Existing Surtacc Pad I HEREBY CEP.TWV THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE LV ACCORDANCE WITH SAN JOAQM COUSTAY ORDINANCES.STATE LAWS.AND RULES AND REGULATIONS. I ALSO CERTJFV THAT 3MY REQUIRED LICENSE IS CURRENT AND ACTIVE WITH IFORNiA CONTRACTORS STATE LICENSE BOARD AND THAT I All LY COMPLIANCE WITH ALL WORKERS CO y SIGN TfT��L� DATE M�"M Imam DEPARTMINT SE Y Application Accepted By Dae ZJA-404- Employee UIO Grout Inspection By Dau SPECIAL Well Pernik Ptmming-lonHy Date C 13 WAIVERReMyed Destruction Inspection 9y Dau Coos4udrd Heti Depth_ f< COMMENTS PE SC info Reaiv_ Cwh Rettaftaed tr Spy 0 tRvefee# Wed WN EHD 43-02-M WEB 9,4t1 Pa:rdt and Drc!annie Woe 9111;2007