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WELL/PUMP PERMIT <br /> SAN JoAQutN Couray EsvotosmEsTAL HEALTH DEPARTMENT 600EAn'*twN STREET-STocKTo,,iCA"M-(2")4iW3420 <br /> NON-REvuNpAsLE ftwmw EXPIRES I YEAR FROM DATE ISSUED <br /> nui <br /> F .4/ <br /> JosAviss ; Cfl,*/Ztp IV, <br /> Citoss STREETPARCEL SIZE q 0 <br /> Ow.'Fia NAME PHONE <br /> --,Rg-/ — <br /> OwsEnArtriam CIMSTATIZZAP <br /> COMMACTOR 7�6fLZ� I..6 <br /> '- <br /> �k� -2. <br /> CONIRACIORAD..Id CSTAISTAT11z"A W , 5 <br /> SUDCONTRACIORADUMS6. CIIYJSTATVZAr-- <br /> Lwm (3C-57 OCC-61 0 D-09 0 Otber Expilt.%TIOND.46711; <br /> GWGKArHWALIN-tWI.xFIO.%'- Co"miles X----- V-------fewaship— Range-- Seellon— <br /> [WIF11-DUSE Domestic:Privatc lodgedur.AMcultur;d 13 Industrial E3 Water Quality Monitoring 0 Soil SaulptingiChairactediation <br /> Fg��� W.W!iyvc.N­ ('cwc:N. eb-4—b. <br /> Tv PE Or WORK E3 New Well ieplacement Well 13 Weil AitcratiomModificalion EITN Halt 0 Other— <br /> oMonitoring Welt(s) nurba"f.eil' n Soil Borings),- 136coiclinical- <br /> 0 Well Destro ion 13 OulAMScmkc Well E3 Out-OF-Smice,Well Rcww3l <br /> ONew pump ghvgcpl,,,t 13 Purey Repair E3 Cross-Connection Repair <br /> WELL CONSTRucrim <br /> Mft Melted C3 Moll Rotary 13 Air Rotary 0 Auger E3 CaMe Toot 0 Push Point 0 Olfk.r <br /> Fropowd Weil Depth­­It 0 Open Bottom 0 Gravel Pack/Gravel Size­--in diarnefer <br /> OCandomorCasing—indiameter I Conductor Cas*Depth—It <br /> Well Casing Diameter—in Thickncs.4GauWAST.MSchell— OSIceil E3Plastic O titainle<s Sicel 0 Other <br /> Groat seal Depth--ii ONeat Cement fP41bbag 15-10gz;1outer) 13 Saud Cement --suck mix/7 gal water <br /> 0 Beritionit,(2014.wfids) 0m. anufactura Spec%solids % Name- OSpoesonFile E3 Specs Submitted <br /> Creat Placement Metbad Ourriped OFree Fall 0 Other ---- 13 Retardant I Acceterrator(ame)--- <br /> PEPM'AL hwtawo Bly 0 mlkr 0 Nnp Conlyactor E3 Olhcr­ <br /> 0 Concrete Pedestal Dimessirms: Width—ft lxngth— duckin0 ChriNy Ba: O Store Pipe <br /> Pump ible 0 Turbine 0 Other-_ HP,-1CJ Pump ScI.,36-Tft StandigW;rt,,Lc,eJ It <br /> WELLDMitt"CrIos 0 Open Bottom 0 Gravel Pack 0 uWasell 0 Other <br /> Welt Diameter_—iri Total Depth--ft DepilitoWater—ft OCasing toboPerforated from---fllo--ft <br /> Sealing Material 0 Neal Cement(941b bag/5-10gal%xrtm) 0-and Ccmnk-- mfr 17 gal water 0 Bentonite POIcts <br /> 0 Bentonite(20": solids) 0Mxrmfac:lurcrSpcc%voids--1; Nww------ OSpecs oaFile OSpm Submiacd <br /> Placement Method 0 Pumped D Free fall <br /> 0 Complete with Mugnuorn Cap Ct bctoA-grade M Complete to Existing Surface Pad <br /> IHEREBY CERTWVTHAT 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 MY REQUIRED LICENSE IS <br /> CURREW AND ACTIVE WITH THE CALIFORNIA.CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> DAm <br /> I t <br /> L I <br /> 'Jawn lip <br /> YMe/V T <br /> ci�/VP <br /> I lilt <br /> 252020 <br /> Qu//v C <br /> 0/V&j"jV00NTy <br /> 'rA L <br /> PARTMENr <br /> DEPARTME I)A <br /> Applifeatim Accoted By Imu A. 13q F <br /> D <br /> Grout InsW.tionRy 'SPECUL Well PI-101lit <br /> ilNv <br /> Atmp <br /> 1111,11pection BY 11CL 11 0 WAIVER ReCdVed <br /> Dc'Inxtion Inspection By Date Constructed Well Depth---It <br /> COMMENTS <br /> PE SC Received CbeddH Amarat Date peradd Invoke g wgum# <br /> Codes 10,110 Remitted Service Rtumilt <br /> qjtj- 5() <br /> ERD4"2-MWEB Well Peniti,and Dlarvillitd.. <br /> 911liZO07 <br /> JUN.0 5 2029 <br /> ENVIRONMENTAL HEALTH <br /> PERMIDSERVICLS '-Io e <br />