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WELL/PUMP PERMIT <br /> SAN JOAQUIN Cotwry ENVIRONIAEN'tAl,HEALTH DEPARTMENT 304 E WEBER AYE.1-FL-S1 0(KTON CA.9SU2 -(209)45$-3420 <br /> NON-REFUNDABLE PERMIT CALL(2091953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED <br /> 77 <br /> Job ADDRESS -22�;Rm .... ---, <br /> CROSS STREET PARCEL WZ 4li-LAND USE APPLICATKYN# <br /> OWNER NAME 4�, PHONE <br /> OWNER ADDREtiS CfTV1STATFJ7AP <br /> CONTRACTOR PRONG <br /> CONTRACTOR ADDRES6 <br /> SVK:0NTRACrOR PROst <br /> SUSCONTRAMRAD091,3S CITYISTATOZIP <br /> Lwrmst t3 Other NUMBER EXPIRATION DATE <br /> GfMRAPHICAL INFORMATION: Coordinatet Y _ 1'0- hip ------ SA clkin— <br /> INTENDED ustmexdc Pr vale " obacu <br /> rstriul <br /> 0 ltrigatioWAVicoltural 0 industrial 0 Water Quality Monitoring a$oil SaViin <br /> 0 Public Water <br /> I!diirara»t from <br /> TYPE Of Woux 14— <br /> Stem —----- <br /> Weil 0 Replacement Well 0 Well AlterationlModificition 0 Test Hole 0 Other <br /> A <br /> 0 Monitoring <br /> 0 Well Destructwm 0 Out-Of-Sermt Well 0 out4X-Scmcc Well kimtrmal <br /> ,Jh�&ew Pump.. 0 Pump Replaccitent 0 Pump Repair 0 crowConnection.RTair <br /> Drilling Method ud Rotary 0 Air Rotary C Aug::, C Cable Tool 0 Push Point 0 01hel <br /> Proposed Well Depth­,",+i, Excavation--- in jismow 00penflotuort -.4ky"vel pack I Gravel Stn—,,,4/it dtartwur <br /> indiartarm I Condui;uo Casi» Depth . .....--'R <br /> Well Casing Diameter <br /> .,2-1. Thickn,:WG-.i;VASTMShed S�,A�Zrie M Stainles Steel 0 0111-n <br /> Groat Seal Dtpth �/Z;&R (3 N.,Cement(94 M bag 15-109W—111) 13 Sand mr 17 P1 wAlcr <br /> entoonte(2W.solids) a Manufacturer SSpec%solids % Nartir 13Specs onfilt CISpots Submilld <br /> Im <br /> Grout PlactratAtMethod OPtroped OFree Fall 0 Cidw 0 Retardant A"Ckmwor(name)­.................. <br /> FgDM'A1. IyjoA",kd By 0 Dallier 0 Pump Contractor -6tnher <br /> 0 coomit Prdtlital Dinwitmions: Width—........... 11 Length... ft Thicl, in 0 Christy Sol 0 Stave Pipe <br /> Ptimp ubmcKstble _J;Turh!nc C Clithcr lip N., ft. stsuita Water Level <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL HE DONE IN ACCORDANCE WITH SAN fq <br /> 4OAQI;IN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE is <br /> CURRENT AAT)ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERSC.0 ENSATOAS.. <br /> UNI 24 HOUR ADVANCE NOTICE Ry. IRED FOR iNiSPECTION's <br /> SIC <br /> TrrLF DATE, <br /> 77-17 <br /> 1A <br /> 11 /IV a A.TH DE <br /> I AJ Il' <br /> I I I t <br /> 1 1 1 <br /> DEPARTMENT I)SE ONLY <br /> ApplicationAcrepttd ,YDA t At" limploy"lO# <br /> Grout 18y D-. 0 SPECIALWAI]aerMit <br /> Puniop)nspection By--"21 Date, 0 WAIVER Received <br /> Destruction Inspoefion By Date Constructed Well Militia <br /> CoMMfiN1;S <br /> if <br /> PE SC Recel ed Amount Data Permit <br /> w4m IDN <br /> Codes Into 8V 'Ash <br /> 1,43 L;L:, i <br /> ... ........... <br /> WELL POMP MMIT <br />