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WELL(PUNIP PEIRIVII'r <br /> SAN JOAaUIN COUNTY ENVIRONMENTAL HEALTH DEPARThIr-N7 .13613 EA1 T-lA;!ELTC1N AVENUE;-SIOCKTONCA!:6205 -12(191.168-:342C <br /> NON-REFUNDABLE PERMIT CALL(209)953--7697 FOR INSPECtIONS EXPPME-S'I YEAF FROM DATE IS::UEC <br /> sp <br /> Jos ADDRESS 2'165 S Airport Way CirylbP �; <br /> CROSS STREET APN <br /> -------PARCELSI.!11161-1>-LANII Jai:APP-ICA1I0I4A1._-­. x <br /> .......... <br /> OVINER NAME V�l <br /> P�"'IIJE 209-Z� <br /> OWNER ADDRESS --_.,_ CIi'Y1SI",TEiZIP ok <br /> CON TRACTOR 3Ak1k Call Ta�460-'-M <br /> OnE! :,rource Drilling pa CON TRACTOR AbDRESS & :�IunC11 YOST1,TEIZIP Dan-Mle,Cal.)4�:,05 <br /> �Allin <br /> SUBCONTRACTOR �Pef*144. <br /> SUBCONTRACTOR ADDRESS—------ 49 o—_—____--__-_ <br /> -Cr Y1SI'(,TE;Zw le)o <br /> C-11? <br /> LICENSE XC-57 C-131 D-09 Oilier 04/300:7 <br /> Alt <br /> AT "T <br /> AL INFORMATION: <br /> �tic-n/A!IPCUItur nc tur S;- lir•y/Al ra. <br /> ? W LII 1 IID <br /> A INTENDED USE )(Do-nestic/Pli, 1�771rrig t <br /> —Usl <br /> GEOGRAPHIC MATION: Coordinates <br /> Pu Ac Water System <br /> lf&ftarenIfroniQ%iiner: 11!rsV-6F-NF.—e T*asr nMav,-hav N <br /> ----gTv""th it <br /> TYPEOFWORK Xl Replacement Vvilll Well A terat <br /> I f'fjf--' <br /> Monitoring IT of wells Soil B,*,nj,g, <br /> — <br /> Out-Of-Service Well Out-01-Servic.q, <br /> EmIrom, 1,M1fiab Division <br /> le filen L Purrip Ri! a-n� <br /> Purfp r <br /> WELL C2NsTRucnoN <br /> Drilling Method XMud Rotary Air Rotary Auger Cable Tool Push Point Other-- <br /> Proposed Well Den&....�. E xcavalon in diameter Oper ED tom XGravel Pack/Gravel Size ii r1zmetet <br /> Ci Go-idt * :rasingjala indiannatet / C:Dnd t C Depth ft <br /> - _-- ;�� Ell) — - <br /> Well Casing Diam,:ter 'R'..in Thjckne--slGau[leiASTM Sched WeeSteirless <br /> Grout Seal Deott-- NeatCernent(941n bag/5-10 gel water) {:,lent_,___jD_3­­­ sack mW"galwatei <br /> l3e,itc.. -J%solids) Other- <br /> Grout Placement Method XPumped Free Fall Other Retardant,Accelerator(name) <br /> PEDESTAL Insta led By Driller Puml.Contractor Ot1er <br /> Concrete Pedestal Dimensions:Width_ft Christy Box Stove Flloe— <br /> PunipS:tt_,­,�,6,Q­ft SandingW.311ml-evel H <br /> PUMP XSU13mersibic Turbine Other <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLlCA'rIQN 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 RE(JUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORl CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION L.A <br /> MINIMUM 24 HOLIRb*iC E16flQUIRED FOR INSPECT113NS-PLEASE CALL.(209)953-7697 <br /> SIGNED Anna Nah ik TITI-r- owner DATE 06/2412015 <br /> R HENT <br /> Ea <br /> C' <br /> 4AVJOA 1? <br /> r <br /> A <br /> Lrar <br /> H IN <br /> 11 WE N�A L.H EALTH <br /> R EF MPQ MR 110,ES <br /> -Tt <br /> EPARTMENT USE ONLY <br /> ID <br /> Application Accepted ByY <br /> P-- Date Area Employee <br /> Grout Inspection B )ate SPECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Ins ection B Date Constructed Well Dapth--fl <br /> u, re-rim 5� <br /> COMMENTS Lil. 61"-Z- Amw- <br /> -WAAC 0 A -w 16 <br /> j t4 <br /> PE SC Received Check#/ Amount DatePermiU <br /> Invoice# Well IDI <br /> Codes Info B Cash R tt d Q--;,;e Requests <br /> ql�G vp -ifsei- 3AXIII 15 Sk 0 0 7.7 rg-3) <br /> Amp- o5%7 V/is 7�2,57VA 6 �i rj T <br /> A ----------- - <br /> EHc13-015 WELL IPJMP P'jRN10 <br /> 4130/12 <br />