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SLIRCOIORACT0R/CoNsuLTANT PHONE <br />SuaccorreacToctiCoorsumurr ADoRess CITY/STA-rElZip <br />LEERSE 0 C-57 3/C-61 C D-09 0 Other NousaztUF) 7k115 EXPIRATION DATE <br />£/3o -2023 0 CONTRACTOR H SUBCONTRACTOR/CONSULTIMT BALING PARTY: 0 OWNER <br />Water System Nacre <br />Public Water System <br />If afferent wen Owen <br />Grout Placement Method j Pumped U Free Fall 3 Other 0 Retardant/ Accelerator (name) <br />Pump Set C Turbine ti Other HP <br />Christy Box I Stove Pipe <br />It Standing Water Level ft <br />WELLJPUMP PERMIT <br />SAN imam CouNTY EINMOINNWIAL HEAuni DEPAYMENY i9B Eosr Hozia_TOM Awprim - groacron CA Mi2G5 -6232 (71B)4138.3420 <br />NON-REFUNDABLE PERiarr www.sigov.orgiehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> <br />20 ( 1.);Vic;VP\c4.9- <br /> <br />p f -:r APN ?PC PARCEL &LE I (ti e' LAND Use Appticoncod it <br />L ) ti $49 yitiL pi. 2o1-o)-07c <br /> <br />5erterti_ 5 Ck 60/1-e_ tart/six-mar <br />ILZkY \ 6, 5 f‘.rYY\ PRINIE 2_bq <br />T)ox Crry/SrATE/Zr etl6t/t.A.k. NZ.% C s <br />OWNER ADDRESS <br />CONTRACTOR <br />CONTRACTOR ADDRESS <br />JOB ADDRESS <br />Dimas SntEET <br />0Yelett NAME <br />Domestic VVeu_ Swim-Leto: ti Otoneul Mineral/Cartoon Bacteria (41591) U Dibromochlonapropene (4392) Li Arsenio (4333) <br />IMBIBED USE 644mestic/Private J aririatrun/Agriculbsal r Industrial 0 Water Duality Menacing 0 Sol Sampling/Characterize <br />Contact Nana or Phone Nurnter <br />TYPE OE Week ii New Weil 1 1 Replacement Wel Well AlterationiModincalion Other <br /> <br />Manaroing Wake)._ It of wells i Sod Boring(s) 0 ot borings t Geotechnical <br />1 I Oul-01.-Service W ii Oul-Or-Sertice Wed Renewal I 1 Cross-Connection Repair <br />I I New Pump RepiaCement I ! Pump Repair I I Raise Wel Casing <br />weal. coNsrauccoN <br />Drilling Method I i Mud Ftotary t Ak Rotary i Auger I I Cable Tool 1 I Push Point i i Other <br />Proposed Well Depth ft Excavation in diameter 3 Open Bottom 0 Gravel Pack/Grawl Size in diameter <br />0 Conductor Casing in diameter / Conductor Casing Depth It <br />Diameter in Thickness/GatigrolASTAI Sched LI Steel 0 Plastic 0 Stai.I.=., Steel H Other <br />Depth ft n Neat Cement (94 lb oag/5-1ogoi water) Ii Sand Cement <br />11 Bentonite (20% sorals) I Other <br />Installed By 0 Driller 0 Pump Contractor 0 Other <br />I I C Pedestal I Ilmercsionv Width ft Length ft Thick <br />I HEREBY CERTIFY THAT 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 />CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPUANCE WITH ALL WORKERS COMPENSATION LAWS. <br />IIVIUM ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />—3—ZOZ/ <br />11. )1E I 2-4 q-2S <br />URI 43430 lint/2019 ww../s.rotr, PERMIT <br />-41 <br />V. <br />DEPARTMENT USE ONLY <br />DaD.tet. <br />Date <br />COMMENTS 1E) t."*-:(G-SD <!-.0 Ntt <br />Date 07 Area Sh(i Employee Oa <br />CD SPECIAL Well Permit <br />0 WAIVER Received <br />Constructed Well Depth <br />Application Accepted By <br />Grout Inspection By r, <br />Pump inspection ByNctlirr%FtrAdlli <br />Sod Bering inspecoon By <br />PE <br />Codes <br />SC <br />Into <br />Raw/Mewl <br />By.. <br />Clweldt! <br />Cosh , <br />Amount <br />Remitted Date, Permit/ <br />Service Request # invoice i wen Olt <br />43e i 0 , 0 .z/AL extom--/- 4 77 (,/clb vi/p6,oq---f ty-i- I <br />I of borirgs <br />Well Casing <br />Grout Seal sack mix/7 gal water <br />TITLE (, ilf*tt t-t-OE DATE <br />to <br />iii