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SAN JOAQUIN COMSTY ENVIROSIDEIETAL WAVED DEPARTMENT 609 FAST Mars STREET . STOCMON CA 952182 - (209)468-M2g <br />NON-REFuNDADLE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br />5/ 6 6 E HdizA/cy LA/ top6 Cil %24'O <br />m'ctoi, -4-Batc-kof--iu Piii) 06/0-700/. sizE 33, oil <br /> pilosE i7L/ - 45-1/6-z_ .5750 & Kerrie--Afg-/v -/i/ cur..., zez5/,cht- <br />.ifkitA7-i..6t...,u,....Q5LOtkrel________ p.Ezoq.__7_Wz_z_zt__ <br /> <br />(p 7r3 CtrviSrAreiZartgatec_PriadO&S.,k' <br />StacronTruicron Pit SE <br />SURCONTILSCTOR ADDRESS <br />LiCESSE 0 C-57 0 11-09 0 Odocr 5.1 smut 2grig.64._ Enria.trift%D.1TE " st-27 <br />GEOGRAPitiCAL INFOInt. to": Coordinates X Y Township Range Section <br />IDS ADDRESS <br />CROSS STRELT <br />OWSER NAME <br />OW+ ER ADDRESS <br />CortritacrOn <br />Cil-n/STATE07,nt <br />NEMO) USE CI DomentioPrivate brismionAgrituitural Ci indestrial Ci WaterQuality Mix-Axing 0 Soil SaraptintChatacterration <br />Cl Public Wa= Sstens <br />If dirk's= Re= <br />Wan foctact Nam or Rea %/umber <br />WELL / PUMP PERMIT <br />Tt,PE Of ViORK 0 New Well 0 Replan:meet Well CI Well Alteration;Modificnion 0 lest Hole 0 Other <br />0 Monitoring Well(s) eranbc• a sas 0 Soil Borineas) parnber 4 Wm, 0 Orotrelmical <br />0 Well Destruction 0 Out-Of-Service Wet; <br />0 New <br />WELL CONSTRL CUM I <br />Drilling Method 0 Mud Rotary 0 Air Re :my 0 ADzer 0 Cable Tool 0 Posh Point °Other 1 <br />?reposed Well Depth ft Excavation in Mamma' Cl Open Bottom 0 Gravel Peck , Gravel Site inSitlivicj <br />Cl Conductor Casing in diameter i Conductor Casing Depth fl Wen Casing Diameter in ThicknesatGaugn'ASTM Seised 0 Steel 0 Plastic Cl Stab:tins; Steel Cl Other fit-AL 7. <br />Grout Seal Depth ft 0 Neat Ceorent We tb tag / 5-10gal miler) 0 Sorel Cno= sack rni. , 7 weterl gal <br />Cl Bn-noditie arl'i,i solids) 0 Manufacturer Spec solids "a Name El Spms =File 0 Specs Submitted . <br />Grout Placement Method Cl Reaped 0 Foes Fall Cl Other 0 Retardant : Acm-lerator (Mot ) <br />PEDESTAL lattiglal Cl ,:friikr 0 Pump Contractor 0 Other <br />0 Coorrete Pedestal Dimensions: Width ft Length tt Thick in 0 Christy Box 0 Some Pipe <br />PUMP )42:Subtnersible ?iefaubine 0 Other RP rtio_ Pump SmAry_ft Steadies Water Level 4W____ fi <br />Wan. DESTRUCTION Cl Opal Eton= 0 Gravel Peek 0 L'acascd Cl Other <br />Well Diameter in Total Depth ft Depth 14 Water it Cl Casing to he Perforated from ft to ft _ _ <br />Smiling MateriA 0 Neat Ccantnt (94 lb hag : 5-10 gal imattry 0 Sand Cormmt mar oift i 7 gal water 0 Bentonite Pacts <br />Cl Bentonite 4201. solids) 0 Manufacturer Sp..n % soh& _ _ % Name Cl Specs= File 0 Specs SubmimM <br />Plactnnent Method Cl Pumped 0 Free Fall Cl Other <br />0 Complete. nit Muslim.= Cap ft Wicw grade CI Complete to Existing Surface PM <br />? itEnEn CE o-y THAT I HAVE PREPARED THIS APPLICATION AND THAT THE i4ORK you, BE DONE IN ACCORDANCE WITH SAN <br />JookourNi col V ORDINANCES, STATE LAWS. AND RULES AND REGULATIONS. ALSO CERTIFif THAT MV REQUIRED LICENSE ES <br />CURP-17‘:T A. AC Ili 4 rivrv ITOR3114 CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPI.LiNCE WITS ALL <br />"RAERS 411 iiiii;1144.fria4/1 <br /> irattficlr g.C.141PAI 111111 h SIUsay 4114 <br />/ pm' <br />mr.t.traf twit' fa: <br />0 Out-Of-Service WCI1 RCOCO. <br />TiTLE rtiOrk_ Darr <br />DEPARTMENT 134 <br />Date /0//3/204; <br /> Dar <br />Li <br />Area 4/elq Employee int! <br />SPEcIAL. Well Permit <br />0 WaivED Received <br />Ccostrutaed Well Depth <br /> <br />Application Acceptant By <br /> 1— <br />Greet Inspection By <br /> <br />Pamp len;nction By CQ'tlet.. IL:it Da _14110(fatt <br /> <br />DT.SOUCO011 inspection By Date <br />COMMENTS <br />Id <br />i-- P I SC <br />i Codes Info lts <br />Recelsex tec Amonnt <br />Remitted Service Date Permit: <br />nem # I invoice # Writ MO i <br />143F/ ,O.So z t jOi 77 110 13 101 WiP004.1 --r I 1 <br />1 <br />43-02416 WEtS <br />9111 ,2007 <br />7,c, 00 01/4-0,0 2rit <br />WeLL Pantit end Deeznalan dot